North Bristol NHS Trust Trust Board Meeting in Public Thursday 31 March 2016 12.30Pm, Seminar Room 5, Learning and Research Centre, Southmead Hospital Agenda 1

North Bristol NHS Trust Trust Board Meeting in Public Thursday 31 March 2016 12.30pm, Seminar Room 5, Learning and Research Centre, Southmead Hospital Agenda 1. Apologies and Declarations of Interest: Harry Hayer, Catherine Phillips 2. Questions from Members of the Public 3. Minutes of the Trust Board meeting held on 28 January 2016 Enc 4. Action Log AY/Enc 5. Chairman’s Business PR/Verbal 6. Chief Executive’s Report AY/Enc

Quality & Performance 7. Patient Story SJ/Verbal 8. Board Member Walkround Programme SJ/Enc 9. Monthly Integrated Performance Report AY/Execs/Enc 10. Equality Annual Report 2014/15 PJ/Enc 11. National Staff Survey PJ/Enc

Strategy and Development 12. Trust Strategy 2016/17 – 2020/21 CB/Enc 13. Cellular Pathology Service Transfer CB/Enc 14. Capital Planning Update SW/Enc

Governance & Regulation 15. Partnership Programme Board and Agreement AY/Enc 16. Workforce Committee Terms of Reference PJ/Enc 17. Annual Declaration of Interests Review PR/Enc 18. Cycle of Business 2016/17 PR/Enc 19. Trust Management Team Report AY/Enc 20. Finance & Performance Committee Report AW/Verbal 21. Charitable Funds Committee KG/Enc 22. Quality & Risk Management Committee Report RM/Enc 23. Remuneration and Nominations Committee AW/Enc 24. Any Other Business 25. Date of Next Meeting Thursday 2 June 2016, 12.30pm, Learning and Research Centre, Southmead Hospital.

North Bristol NHS Trust

Minutes of the Trust Board Meeting held in public on 28 January 2016 in Seminar Room 4, Learning and Research Building, Southmead Hospital

Present: Mr P Rilett Chairman Ms A Young Chief Executive Mr J Everitt Non-Executive Director Dr C Burton Medical Director Mr K Guy Non-Executive Director Mr N Darvill Director of Informatics Mr R Mould Non-Executive Director Ms K Hannam Director of Operations Ms E Redfern Non-Executive Director Mr P Jones Interim Director of People and Organisation Health Mr A Willis Non-Executive Director Mrs S Jones Director of Nursing Mrs C Phillips Director of Finance Mr S Wood Director of Facilities

In Attendance: Dr M Baird Deputy Medical Mr E Sanders Trust Secretary Director Ms S Cownie Alcohol Nurse Mr N Stibbs Corporate Services Specialist (until item Manager 01/04 Mrs C Lang Acting Head of Dr T Valliani Consultant Marketing and Gastroenterologist (until Communications item 01/04) Mr R Quinn Alcohol Nurse Specialist (until item 01/04)

Observers: Mr Colin Puckett, Staffside Chairman

Action

TB/16/01/01 Apologies and Declarations of Interest

Apologies were received from Prof Nishan Canagarajah, Non-Executive Director and Mr Harry Hayer, Director of People and Organisation Health No interests were declared in the papers presented.

TB/16/01/02 Questions from Members of the Public

There were no questions from the public.

TB/16/01/03 Patient Story Sue Jones, Director of Nursing, introduced to the Board, Dr Talal Valliani, consultant gastroenterologist, Ms Sally Cownie and Mr Ryan Quinn, alcohol specialist nurses. Mr Quinn’s post was funded by the Bristol and South Gloucestershire Councils. Ms Cownie, reported that a 48 year old man presented himself to the Emergency Department and was admitted a week before Christmas,

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vomiting blood. He had presented on a number of other occasions and endoscopy had identified varices. He had previously not engaged in any therapy or treatment and professed to staff that he would probably discharge himself. He was seen on the ward by the specialist staff with his partner of long standing and was provided with a clear explanation, in understandable language, of his long term health, what he could do and withdrawal symptoms. This had been easier to do by being in a single room. A view of what could happen in six months if he stayed as an inpatient for a while and what might happen if he continued to drink was explained. He stayed in hospital that weekend and complied with all the nursing guidance with positive help from his partner. He had been seen that day and appeared to be relaxed. He had engaged well with services outside the hospital and was getting support. Knowledge that additional help was available over the phone was helpful and she had been able to link him with a dietician. Sue Jones said that alcohol dependent patients could be very disruptive and be inpatients for long periods and Dr Valliani said that the Trust was lucky to have the expertise of Sally and Ryan. CQUIN funding had been helpful in providing the service and the Trust’s liver clinic was working with primary care and focussing on earlier identification of issues. Liz Redfern, Non-Executive Director, questioned the long term benefits for the patient and Dr Valliani said that he was quite young and if he remained compliant would be a potential recipient for a liver transplant. Robert Mould, Non-Executive Director asked about links with other organisations and Sally Cownie said that she and Ryan bridged the hospital service with community services and arranged packages of care to fit the individual depending on physical, psychological and fitness attributes. Dr Valliani said that he would like to offer screening for alcohol in endoscopy and outpatients. Andrew Willis, Non-Executive Director, questioned whether the Trust was looking at cases or models that looked at the whole pathway and was advised that South Gloucestershire CCG was investigating the latter aspect. The Board thanked the three clinicians for presenting the patient story.

TB/16/01/04 Minutes of the Trust Board meeting held on 26 November 2015

The minutes were approved as a true and correct record of the meeting.

TB/16/01/05 Action Log

The Trust Board approved the closure of actions as noted on the action log and noted progress as follows:

Action 25 – a risk summit was being held the following day and the

action was considered closed. Andrew Willis questioned how the Board could improve its links with CCGs and it was agreed to discuss this after the summit.

Actions 57 and 58 – To be considered at the March 2016 meeting.

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Action 11 – To be considered at the March 2016 meeting. Action 23 – ongoing action Action 24 – will be reported through Workforce Committee and, therefore, the Board agreed to close the action. PJ Action 28 – The Board agreed that this should be reported through Quality and Risk Management Committee (Q&RMC).

TB/16/01/06 Chairman’s Report

Peter Rilett reported that he had no issues to discuss other than those on the agenda.

TB/16/01/07 Chief Executive’s Report

Andrea Young, Chief Executive, presented her report on the external environment impacting on the Trust. She highlighted the recognition of the Trust’s catering department as a national leader in hospital and staff food, for its Soil Association Food for Life catering mark (for patients) and Bronze mark for staff. In addition there were a considerable number of events and actions being undertaken for staff health and well-being. The Board noted the report and the appointment of five new consultants.

TB/16/01/08 Emergency Department CQC Inspection Report

Sue Jones presented the report from the Care Quality Commission from its visit to the Emergency Department on 27 November 2015. It

confirmed that a number of improvements had been made since the hospital’s inspection in 2014, in particular that the Warning Notice conditions had been fully met.

Eric Sanders, Trust Secretary, noted that South Gloucestershire

Council had been pleased to view the report and the Board agreed that the action plan should be considered by the Q&RMC. RM

TB/16/01/09 Integrated Performance Report

Andrea Young presented the Integrated Performance Report (IPR) with data to the end of December 2015. She highlighted the failure in December to achieve the A&E four hour target with bed pressures remaining the main source of breaches and some impact from the switch of patient administration systems. Waiting times for minor injuries had been included in a small number of breaches and many actions had been put in place. Much escalation capacity in the hospital was being utilised. The Trust’s performance to reduce over 18 week waiters was better than projected and it was expected that six out of the eight cancer targets would be achieved. The Trust’s ‘’harm free’ rate was above the national average and there had been no grade 4 pressure ulcers in the year and no grade 3’s since September 2015. There had, however, been some mixed sex breaches as a consequence of using escalation capacity. 54 new staff had joined the Trust and 41 offers had been made to nurses following an open day in January. On finance the Trust was £16 million adverse to plan mainly

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due to lower than planned income and pay overspends. Kate Hannam, Director of Operations, said that the source of breaches in ED was roughly split 75/25 bed pressures/PAS switch. Four internal critical incidents had been called and black escalation covered most of January. 33 extra beds were open every day but evidence showed that quality had been unaffected. Andrew Willis said that it appeared that the performance of ED had stabilised but was not improving and Kate Hannam said that a trajectory had been agreed to achieve 95% by July, with February and March unlikely to show great improvements. Breaches were now happening in the morning instead of the evening and the discharge lounge was being opened at 08:00 each day. Liz Redfern questioned whether there had been progress on the Discharge to Assess (D2A) project and Kate Hannam reported that for South Gloucestershire patients Sirona was delivering the Pathway 1 target but a 75% increase in productivity for Pathway 2 patients was required. Bristol had supplied ten extra beds but was significantly short of its plans. Overall CCGs had only hit 25% of their plans and Bristol had difficulty in evidencing any resource increase. In addition the numbers of delays for North Somerset patients was a growing problem. Andrea Young said it was clear that D2A had been optimistic in its planning. Those needing the greatest care were using the service heavily and there were queues forming and it appeared that acuity was increasing. The Board noted the performance of Cancer services and that neither the 62 nor 31 day pathways were anticipated to achieve their targets in December predominantly because of issues around the urology pathway. Referring to the performance against the Venous Thromboembolism Screening target, Chris Burton, Medical Director, said that the target was hit but coding issues meant that recording of the screening was not reported on time. Sue Jones reported that nurse expenditure on inpatient wards had reduced because of a decline in agency expenditure and in December this had reduced to 5.5% of pay. The Falls rate had fallen below the national average although there had been two serious injury falls in December. Some of the Sign up to Safety funding had been directed at a Falls Lead nurse to deliver training of ward staff and some directed at Pharmacy for medication reviews. Chris Burton noted that there had been a further MRSA case in January taking the total to the year to date to three. With high numbers of MSSA and C Diff cases, action was being focussed on management of indwelling devices. The Neonatal Intensive Care Unit had experienced an increase in Serratia Mercescens infections with six cases since October 2015 and an internal incident meeting had recommended actions. He reported that an evaluation of deaths would be taken to Q&RMC in March 2016 and although the standardised mortality ratios continued to show lower than national benchmarks the Trust would be expected to be reporting 40 to 50 lapses of care attributing to death. About 68% of deaths in hospital had been scrutinised in the previous year. The implementation of a national tool for analysis of deaths may require considerable clinical time. From the patient experience section,Sue Jones highlighted that the ED

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had achieved a Friends and Family Test response rate over 17% and the top inpatient achiever was Gate 6b. The number of overdue complaints had increased and were due to be brought back into line by the end of March 2016. Under the Well-Led section Paul Jones highlighted: • Much management work was being undertaken for the transfer of the Community Childrens’ Health Partnership service • The re-award of the Two Ticks symbol • The signing of the Trust’s Dignity and Respect statement • The launch of the Religion and Belief guidance in Facilities for which Liz Redfern had agreed to act as champion • 610 whole time equivalent new recruits had joined the Trust since the beginning of the year and turnover had remained static since August 2015 • Overall sickness absence was 4.6% and this resulted in an annual cost to the Trust of about £3.5 million in temporary staffing Catherine Phillips, Director of Finance, reported that the Trust was now £38 million overspent which was £16 million adverse to plan. Particular areas of concern were contract income, £8 million below plan, pay expenditure, £5.8 million above plan and non-pay expenditure £2.5 million above plan. Pay expenditure reflected above plan use of agency and bank staff and although this had reduced recently the Trust was still 176 Whole Time Equivalent (WTE) staff over establishment. The cash position was being monitored daily and the Trust Development Authority had been advised of the Trust’s cash position. Liz Redfern questioned whether the Trust was yet out of the phase when it was recruiting more staff but still had large numbers of supernumeraries. Catherine Phillips said this was largely over but there were still some pressure points, for example in the Intensive Care Unit and Theatres so it appeared that extra staff were dealing with both acuity and increased activity. The Board discussed the monthly Board Compliance statements concentrating on 4, 8 and 10. It was noted that the recovery trajectory was no longer being met and the Auditors were likely to send a formal letter to the Secretary of State in relation to the Trust as a going concern. Statement 8 was felt to be about plans rather than outcomes and the continued performance against cancer and ED targets meant that the answers should remain as they had been in December.

TB/16/01/10 Capital Planning Update

Simon Wood, Director of Facilities, presented the monthly update on capital projects and reported that the adjudication process on the dispute with Vinci regarding the construction of Pathology Phase 2 had been extended further to 4 February 2016. Catherine Phillips reported that the proposed PFI refinancing would not result in any change of partners but was an opportunity to take advantage of lower interest rates. Advisers had been appointed and

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costs of up to £200,000 might be incurred.

TB/16/01/11 Finance and Performance Committee Report

Andrew Willis, Chairman of the Finance and Performance Committee, presented the report from its meeting held on 16 December 2015. The Board agreed with his request to remove the effectiveness survey attached to the report, for remodelling.

TB/16/01/12 Quality and Risk Management Committee Report

Robert Mould, Chairman of the Quality and Risk Management Committee, presented the report of its meeting held on 18 January

2016. The Board noted the ‘deep dive’ into end of life care services and agreed to the request that the Board discuss the value and commitment to the executive and non-executive walkrounds at its next development session. ES

TB/16/01/13 Audit Committee Report

Ken Guy, Chairman of the Audit Committee, presented the report of its meeting held on 18 January 2016. He noted that the Local Counter

Fraud work had achieved only 54% of its planned days partly due to the late start of the contract and the Director of Finance would keep this under review at her monthly meetings.

Ken Guy also pointed out that significant volumes of non-NHS debt had

been referred to a debt collector and that the Audit Committee recommended that the Board nominate it as an auditor panel to enable it to appoint external auditors by 1 January 2017. A further recommendation was for the Annual Report and Quality Account to be prepared for the annual public meeting in September 2017 as a combined publication in the Trust’s usual format with an annual report strictly following DH guidance ready with the final accounts for 2015/16. The Board approved the two recommendations. ES

TB/16/01/14 West of England Academic Health Science Network Board Quarterly Report

The Board received and noted the tenth quarterly report from the Board of the West of England Academic Health Science Network.

TB/16/01/15 Any Other Business

In response to a request from John Everitt, Non-Executive, Catherine Phillips agreed that the impact on budgets should be made explicit on all reports to the Board. CP/ES

TB/16/01/16 Date of Next Meeting

The next meeting was to be held on Thursday 31 March 2016 at 12.30 pm in Seminar Room 5, Learning and Research Centre, Southmead Hospital.

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North Bristol NHS Trust Trust Board (Public Session) Action Log 2014

Status A Agenda - this meeting ACTION LOG O Open C Closed Meeting Minute Ref Action Action Owner Review Date Status Info. Date No. (s) 26-Nov-15 TB/15/11/13 23 Directorates to nominate a number of staff as PJ 31-Mar-16 O advocates in supporting staff in raising concerns 26-Nov-15 TB/15/11/19 28 Executives to consider an overall improvement AY/CB/ 31-Mar-16 O methodology SJ 28-Jan-16 TB/16/01/11 4 Effectiveness appendix on F&PC report to be AW 31-Mar-16 O remodelled 27-Nov-14 TB/14/11/13 57 Draft objectives for Equality to be brought to Board in PJ 30-Apr-15, To be discussed by Workforce Committee in March 26-Nov-15 & A Summer and Board in November. 31-Mar-16 Postponed to early 2016. Item 10 27-Nov-14 TB/14/11/13 58 Action plan for moving the Trust to Equality Delivery PJ 30-Apr-15, To be discussed by Workforce Committee in System 2 grade 'achieving' (green) required. 26-Nov-15 & A Summer and Board in November. 31-Mar-16 Postponed to early 2016. Item 10 26-Mar-15 TB/15/03/10 11 Overarching strategy to be approved by Board at first CB 4-Jun-15, 25- Postponed to September and then further June meeting Jun-15 & 31- A postponed following Board away days. Item Mar-16 12 26-Nov-15 TB/15/11/09 20 Timeline for compliance with Board Statement 10 to AY 28-Jan-16 Discussed at January meeting C be discussed at January meeting 26-Nov-15 TB/15/11/09 21 Volunteer information to be added to Patient SJ 28-Jan-16 C Experience section of IPR 26-Nov-15 TB/15/11/11 22 Two or three metrics to be chosen from surveys to SJ 31-Mar-16 Discussed at March Q&RMC focus on for Patient Experience Improvement Plan O and taken to Q&RMC 26-Nov-15 TB/15/11/13 24 Communication and Education plan for ensuring staff PJ 31-Mar-16 Discussed at March Q&RMC and Rob understand range of options and support through C Mould, as Speak Up Champion will hold which to raise concerns to be developed open sessions in first quarter of 2016/17 26-Nov-15 TB/15/11/15 25 Chairman and Chief Executive to discuss Winter plan PR/AY 28-Jan-16 Discussed with CCGs and to be dealt with at C with Bristol CCG risk summit 26-Nov-15 TB/15/11/17 26 Action plan progress on four core EPPR standards to KH 31-Mar-16 Q&RMC assured at March meeting C be reviewed 26-Nov-15 TB/15/11/21 29 Charitable Funds Committee to regularly review KG/CP 28-Apr-16 O ethical values of the investment portfolio 28-Jan-16 TB/16/01/05 1 Board to discuss closer links with CCGs in a AY 28-Apr-16 O development session North Bristol NHS Trust Trust Board (Public Session) Action Log 2014

Status A Agenda - this meeting ACTION LOG O Open C Closed Meeting Minute Ref Action Action Owner Review Date Status Info. Date No. (s) 28-Jan-16 TB/16/01/08 2 Response from Trust to CQC December inspection SJ 31-Mar-16 Overall CQC action plan with changes C report to be discussed at Q&RMC discussed at March meeting 28-Jan-16 TB/16/01/09 3 Report to Q&RMC on evaluation of deaths in NBT CB 26-May-16 O 28-Jan-16 TB/16/01/12 5 Walkrounds to be discussed at next Board ES 25-Feb-16 Discussed at February meeting C Development session 28-Jan-16 TB/16/01/15 6 Board papers to explicitly report on budget impacts ES 28-Apr-16 O North Bristol NHS Trust Trust Board (Public Session) Decision Log 2015 DECISION LOG Meeting Minute Date Ref No. Decision 28/1/16 TB/16/01/09 1 Board compliance statements 8 and 10 to continue to be positive and negative respectively 28/1/16 TB/16/01/13 2 Audit Committee appointed as auditor panel to choose external auditors 28/1/16 TB/16/01/13 3 Changes to Annual Report format approved

Report to: Trust Board Agenda item: 6

Date of Meeting: 31 March 2016

Report Title: Chief Executive’s Report

Status: Information Discussion Assurance Approval

Prepared by: Eric Sanders, Trust Secretary

Executive Sponsor (presenting): Andrea Young, Chief Executive

Appendices (list if applicable): Appendix 1 - Final West of England Devolution Agreement Appendix 2 – Summary of South Gloucestershire CCG Governing Body Papers – 24 February 2016 Appendix 3 - Report from West of England Academic Health Science Network Board

Recommendation:

The Trust Board is asked to note the contents of the report.

North Bristol NHS Trust

1. Purpose Negotiations have also been supported by the West of England Local Enterprise Partnership (LEP). 1.1. To present an update on local and national issues impacting on the Trust, and to provide an update on 3.3. This agreement will go to all four councils for consultant appointments and documents which have consideration, who will then make a decision on how been signed or sealed. to proceed. The move would represent a major change, bringing decisions on transport, investment, 2. Background funding, skills training, business support, housing 2.1. The Trust Board should receive a report from the and strategic planning to the West of England and Chief Executive to each meeting detailing important away from central government. changes or issues in the external environment (e.g. 3.4. The agreement will see: policy changes, quality and financial risks in the health economy, PBR new tariffs etc.). 3.4.1. The creation of a West of England Investment Fund to deliver infrastructure to boost economic 2.2. Following the implementation of a revised approach growth. Government will provide £30m a year for to Flash Reporting, the Chief Executive report is now funding towards this fund for 30 years, or £900m. more focused on the external environment. Additional sums from other sources take the total 3. Devolution Deal – West of England over and above £1 billion. 3.1. A devolution deal offering to boost the West of 3.4.2. Devolution of multi-year transport budgets, England economy with over £1 billion worth of enabling the area to deliver more ambitious investment and bring new opportunities for transport projects with greater certainty. This will businesses and residents was announced by be coupled with further powers over transport Chancellor, George Osborne in the budget speech including the ability to franchise bus services and on 16 March 2016. responsibility for a Key Routes Network of roads. 3.2. Leaders of the West of England councils1, the Mayor 3.4.3. Responsibility for the new Adult Education Budget of Bristol and the Government have negotiated the from 2018/19, helping the West of England proposed agreement seeking to devolve significant ensure that adult skills provision meets the needs powers, funding and responsibilities to the region. of local businesses and learners. 3.4.4. Enhanced powers to speed up the delivery of new housing where most needed and resist 1 Bath & North East Somerset, Bristol City, North Somerset and South unsustainable developments that are not in line Gloucestershire with jointly agreed planning policies. This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under a 'closed section' of any meeting. 2

North Bristol NHS Trust

3.4.5. Closer cooperation between government and the • Estimated cancellation of 369 outpatients West of England on promoting trade and • 77 junior doctors not striking investment with the region. • 162 junior doctors striking 3.4.6. Co-design with the Department of Work and • 222 senior doctors supporting (Associate Pensions (DWP) of the new National Work and Health Programme focusing on supporting those Specialist and Consultant) with a health condition or disability and the very long-term unemployed. The West of England will 5. Plans for improvements in safety and transparency also bring forward a pilot scheme to offer within the NHS intensive support for those furthest from the 5.1. The Secretary of State for Health, Jeremy Hunt, has labour market. announced plans to improve safety and 3.4.7. Support for realising the potential of the Bristol transparency within the NHS. The plans include and Bath Science Park, the Food Enterprise Zone • an independent Healthcare Safety Investigation at Junction 21 of the M5 and the development of Branch the West of England Growth Hub. • legal protection for anyone giving information 3.5. The final West of England Devolution Agreement is following a hospital mistake presented in Appendix 1. • from April 2018, expert medical examiners will 4. Junior Doctors – Impact of Industrial Action independently review and confirm the cause of 4.1. Members of the British Medical Association (BMA) all deaths, as originally recommended by the undertook strike action from 08:00 on Wednesday 9 Shipman Inquiry, and subsequently by Robert March 2016 to 08:00 on Friday 11 March 2016 Francis following the events of Mid Staffs. where they provided emergency care only. • A Learning from Mistakes League 4.2. During this time the Trust setup a command centre 5.2. The learning from mistakes league, which ranks all to oversee business continuity and extra cover was health trusts in England according to their ability to provided by consultants and nursing staff. learn from mistakes, ranked the Trust at level three 4.3. The impact from industrial action on routine care (significant concerns). This was due to having one was: red flag in the staff survey around fairness and effective procedures for reporting errors, near • Cancellation of 17 elective inpatients misses and incidents. • Cancellation of 37 day case patients This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under a 'closed section' of any meeting. 3

North Bristol NHS Trust

5.3. No risks were identified in relation to potential under (BNSSG) area in relation to the development of a reporting (including severe harm or death), harmful Sustainability and Transformation Plan (STP). incidents and reporting consistency in the last six 8.2. The STP will bring together the work of 3 CCGs, 3 months. acute providers, 3 community providers, 3 local 5.4. Actions to address the issues from the staff survey authorities and a provider of mental health services are underway as reported to the Trust Board last – and involve over 100 GP practices. month. 8.3. Work on the BNSSG STP is underway, and leaders 6. National Whistleblower Guardian across the system have agreed that Robert Woolley, the CEO of University Hospitals Bristol NHS 6.1. Dame Eileen Sills has stepped down as national Foundation Trust (UHB), will lead the development guardian for NHS whistleblowers after two months in phase of the STP. role stating that it was “not possible” to combine the role with being nursing director of Guy’s and St 8.4. In recognising the scale of the challenge in the Thomas’ FT BNSSG area, the STP will focus its priorities around addressing the identified gaps in the three key areas 6.2. The CQC have announced that the appointment of Health and Wellbeing, Care and Quality and , with t process would be started immediately he work Finance and Efficiency, with the overall aim of of setting up the office of the national guardian to demonstrating how we will deliver and maintain continue as planned, with a focus on supporting and system-wide sustainability across each of these working with freedom to speak up guardians in NHS areas. trusts and foundation trusts. 8.5. The final STP needs to be submitted by 30 June 7. NHS Pay Announcement 2016 7.1. All NHS staff will receive a 1 per cent pay rise in 9. Lord Prior Visit – 16 March 2016 2016-17 after the Department of Health accepted the latest pay review body recommendations. The pay 9.1. Lord Prior, the Parliamentary Under-Secretary of rise will apply to Agenda for Change staff, doctors State for NHS Productivity, visited the Trust on 16 and dentists, and is being applied across the board. March 2016. The programme included meetings with the Chief Executive and Chairman, a session with 8. Sustainability and Transformation Plan managers and clinicians from the orthopaedic 8.1. An initial submission has been made on behalf of the service, a tour of the Brunel building and then a Bristol, North Somerset, and South Gloucestershire round table discussion with staff.

North Bristol NHS Trust

9.2. The purpose of the visit was fact finding and to see • Outstanding Achievement, which was won by first-hand the work of the Trust’s orthopaedic Neurologist Alan Whone, who is based in the surgeons and the new Brunel facilities. Bristol Brain Centre at Southmead Hospital. 10. Update on Weston Area Health NHS Trust • The Breast MRI Team based at Southmead 10.1. To be updated verbally Hospital, which works in partnership with BUST (Breast Unit Support Trust), won the Best Patient 11. South Gloucestershire CCG – Summary of Board and Public Involvement Award for their work to Papers improve the experience of women who come in 11.1. The CCG Governing Body met on 24 February 2016 for an MRI. and considered a number of papers including • In the Hospital Team of the Year category, the Business Case Investments for 2016/17, the CCG’s Enhanced Recovery Team, won for its work to financial position and performance. A summary is improve patient safety and help patients to get provided in Appendix 2. back to full health after surgery. 12. Appointment of a New Director of Director of Post • Consultant Plastic Surgeon James Henderson Graduate Medical Education received the Rising Star Award, after receiving 12.1. Following the resignation of Dr Joe Unsworth as the recognition for both his surgical work and his role Director of Post Graduate Medical Education, as an honorary senior lecturer. Katherine Finucane, a consultant in Dermatology, 14. Report from West of England Academic Health Science has been appoint to take over this leadership role. Network Board 13. Inaugural Bristol Health and Care Awards 14.1. The latest report from the West of England AHSN is 13.1. The awards held by the Bristol Post and sponsored attached in Appendix 3. by Bristol Health Partners on 10 March 2016 saw 15. Recent Consultant Appointments health and care staff from across the city celebrated in 15 categories. The shortlist for the awards 15.1. The following consultant appointments have been featured 17 North Bristol NHS Trust nominations in made since 19 January 2016: eight categories. Interview Date Name Role 13.2. There were four winners from the Trust including: 26 January 2016 Thomas Wright Plastic Surgery 2 February 2016 Kathryn Urankar Neurpathology

North Bristol NHS Trust

Interview Date Name Role 9 February 2016 Pavel Kavcic Interventional Radiology 23 February 2016 Mario Teo Neurosurgery

16. Recommendations 16.1. The Trust Board is asked to note the contents of the report.

North Bristol NHS Trust

Appendix 2 – Summary of South Gloucestershire CCG • Tier 3 CAMHS - increase capacity in the Child and Governing Body Papers – 24 February 2016 Adolescent Mental Health Service in South Investment Decisions 2016/17 Gloucestershire to meet the national 18 week waiting times target The CCG Governing Body received a recommendation to approve investments in the following schemes which would be funded through mental health growth monies: The CCG Governing Body received a recommendation to approve investments in the following schemes which would be • Autism service - Specialist autism service to progress funded via the Transformation Fund towards being compliant with NICE recommendations • Tier 3 Weight Management Service • Mental health control room triage - funding and implementation of a Police Control Room Integrated • Community Falls Service - for older people over the age Mental Health Triage Function for the Avon and of 65 Somerset region. The objective of the Triage Function • Alcohol Interface Service – Funding for the Alcohol will be to provide an effective first point of contact Interface Nurse Pilot intervention by Avon & Somerset Constabulary and Mental Health Services resulting in the identification of • Integrating Care – Living Well with Long Term - To the most appropriate pathway for individuals suffering improve the lives of people with long term conditions, from mental health issues and thereby reduce their use of health and social care • Dementia advisors - Supporting people living with • St Peter's Telephone Advice Line - end of life care dementia after diagnosis coordination centre test • South Glos dementia action alliance • new Electronic Palliative Care Coordination system (EPaCCs) for BNSSG • Care home liaison service - Multi-disciplinary team to support care homes manage more challenging residents • Marie Curie Twilight Service - specialist end of life visiting service • Early intervention in psychosis - To meet the new Early Intervention in Psychosis access and waiting time • Cluster Integration Project Support - project standard management resource to continue with the delivery of our Happy, Healthy and at Home: Cluster Integration • CAMHS Tier 2 counselling - To expand capacity in the Project Tier 2 Counselling service for Children and Young People with Off the Record

North Bristol NHS Trust

• Care Homes Pharmacist – funding for an additional • Year to date the CCG has delivered £6.394m of QIPP specialist care homes pharmacist to undertake against a plan of £8.187m. The year-end forecast medicines reconciliation and medication review for delivery is £9.8m against a plan of £10.10m. residents in care homes and improve medicines • The CCG position includes an unmitigated risk of £2.5m management. principally as a result of an additional £6.5m included in The CCG Governing Body received a recommendation not to the plan to ensure activity met national referral to approve investments in the following schemes: treatment times. In addition, there has been a deterioration in the CCG forecast spend for Continuing • Dermatology - management of 2WW skin appointments Healthcare in a primary care setting and enhancing community dermatology services with additional dermatology nurse Performance Position support. The CCG’s performance is heavily linked to the Trust’s • Exercise For Lower Back Pain - pilot structured exercise performance against A&E, Cancer and Referral to Treatment programme for South Gloucestershire residents with Targets. The summary below highlights other performance persistent non-specific low back pain which may be of interest to the Board: • Specialist Neurological Rehab – Level 2 – Funding for • Ambulance response times have not been met by South new capacity for 2b specialist rehabilitation at the Brain West Ambulance Service NHS Foundation Trust Injury Rehabilitation Centre at Frenchay (BIRU) (SWAST) since June 2015. Year to date performance is as follows: • Lymphoedema - Investing in the Community Lymphoedema Service provided by North Somerset Ambulance Measures for NHS YTD Standard Community Partnership South Gloucestershire Performance • Personal Health Budgets for people with Long Term Cat. A (Red 1) 8 minute response 75.0% 64.3% Conditions and Mental Health Cat. A (Red 2) 8 minute response 75.0% 59.4% Financial Positon Cat. A 19 minute transportation 95.0% 93.9% The CCG’s financial position was presented which is summarised below: • NHS111 response times are not being achieved year to • The CCG is reporting a year to date deficit of £7m date: against a plan of £5.558m deficit. Forecast to year end is a £8.403m deficit against a £6.672m deficit.

NHS111 Standard YTD Performance Percentage of calls answered within 60 seconds 95.0% 94.8% Percentage of abandoned calls after 30 seconds waiting time <5% 0.9%

• The index chart below for A&E attendances shows where proportional changes were occurring. The illustration below shows the results across All Providers, NBT, Yate MIU and the RUH, Bath indexed back to September 2013.

RUH

UHB

Yate MIU

ALL

NBT

WEST OF ENGLAND DEVOLUTION AGREEMENT

…………………………………… ……………………………………… The Rt Hon George Osborne Councillor Nigel Ashton Chancellor of the Exchequer Leader of North Somerset Council

…………………………………… ……………………………………… The Rt Hon Greg Clark Councillor Tim Warren Secretary of State for Communities Leader of Bath and North East and Local Government Somerset Council

……………………………………… ……………………………………… Lord Jim O’Neill Mayor George Ferguson CBE Commercial Secretary to the Treasury Mayor of Bristol City Council

……………………………………… ……………………………………… Councillor Matthew Riddle Robert Sinclair Leader of South Gloucestershire Interim Chair of the West of England Council LEP

Contents

Overview page 5

Summary table page 6

Governance page 7

Fiscal page 7

Skills (19+) page 8

Skills (16 – 18) page 10

Employment page 10

Supporting and attracting business page 11

Energy page 13

European funding page 13

Housing and planning page 13

Transport page 15

Under this geography page 16

West of England Combined Authority commitments page 16

WEST OF ENGLAND DEVOLUTION AGREEMENT

This document sets out the terms of a proposed agreement between the government and the Bristol Mayor and other Council Leaders of the West of England to devolve a range of powers and responsibilities to a West of England Combined Authority and a new directly elected mayor for the city region. This Devolution Agreement marks the next step in a progressive process of devolution of funding, building on the City Deal (agreed in 2012) and the Growth Deals (agreed in July 2014 and January 2015).

This agreement is directed at building upon the area’s successful local economy, to increase its contribution to the national economy and to increase the prosperity of local residents. The city region generates some £30.8 billion in economic output (GVA) and is home to 1.1 million people. The West of England geography closely matches the functional economy of the city region (85 per cent of people that work here also live here). The city region has significant industrial clusters1 in creative, health, advanced engineering, transport & aerospace, real estate, food & drink, and insurance & financial jobs. There is also a growing cluster around ‘low carbon energy’ – notably, Bristol was awarded European Green Capital for 2015.

This Devolution Agreement marks the next step in the transfer of resources and powers from central government to the West of England. The West of England will continue to have further devolution dialogue with the government in the future.

1 http://www.westofenglandlep.co.uk/about-us/strategicplan

Summary of the proposed Devolution Agreement agreed by the government and the Bristol Mayor and other Council Leaders of the West of England.

A new, directly elected West of England Mayor will act as chair of the West of England Combined Authority and will exercise the following powers and functions devolved from central government:  Responsibility for a consolidated, devolved local transport budget, with a multi-year settlement.  The ability to franchise bus services, subject to necessary legislation and local consultation, which will support the Combined Authority’s delivery of smart and integrated ticketing.  Responsibility for a new Key Route Network of local authority roads that will be managed and maintained by the Combined Authority on behalf of the Mayor.  Powers over strategic planning, including to adopt a statutory spatial development strategy which will act as the framework for managing planning across the West of England region. The West of England Combined Authority, working with the Mayor, will receive the following powers:  Control of a new additional £30 million a year funding allocation over 30 years, to be invested in the West of England Single Investment Fund, to boost growth.  Responsibility for the 19+ Adult Education Budget, which will be devolved from academic year 2018/19.  Joint responsibility with the government to co-design the new National Work and Health Programme designed to focus on those with a health condition or disability and the very long term unemployed. The West of England Combined Authority will also bring forward a proposal to pilot more intensive support for those furthest from the labour market. In addition:  The government will work towards closer cooperation with the West of England Combined Authority on trade and investment services, including joint activities with UKTI.  The government will work with the West of England Combined Authority to realise the economic potential of the Bristol and Bath Science Park and Food Enterprise Zone at J21 Enterprise Area, and to support the development of the West of England Growth Hub.  The government will work with the West of England Combined Authority to agree specific funding flexibilities. The joint ambition will be to give the West of England Combined Authority a single pot to invest in its economic growth. Further powers may be agreed over time and included in future legislation.

Governance 1. This agreement is subject to the formal ratification of the constituent councils of Bristol City Council, Bath & North East Somerset Council, North Somerset Council and South Gloucestershire Council that currently make up the West of England. This agreement is also subject to the statutory requirements including parliamentary approval of the secondary legislation implementing the provisions of this agreement. This agreement protects the integrity of the four existing West of England local authorities. 2. As part of this agreement, the West of England constituent councils will establish a Combined Authority and adopt the model of a directly elected mayor for the area of the West of England Combined Authority. The first election for the directly elected Mayor will be held in May 2017. The strength of the governance arrangements of the mayoral combined authority will be commensurate with the powers of that authority, including all new devolved powers, recognising that strong governance is an essential prerequisite of any devolution of powers to a city region. There is no intention to take existing powers from local authorities without agreement. 3. The directly elected Mayor of the West of England Combined Authority will autonomously exercise new powers. The West of England Combined Authority Mayor will chair the West of England Combined Authority, which will be comprised of the other members of the Combined Authority. 4. The West of England Combined Authority, including the Mayor, will be scrutinised and held to account by the West of England Overview and Scrutiny and Audit committee(s). The West of England Combined Authority Mayor will also be required to consult the West of England Combined Authority on his/her strategies, which it may reject if two- thirds of the constituent council members agree to do so. The West of England Combined Authority will also examine the Mayor’s spending plans and will be able to amend his/her plans, if two-thirds of the constituent council members agree to do so. 5. Proposals for decision by the West of England Combined Authority may be put forward by the Mayor or any constituent Member. The Mayor will have one vote as will other voting members. Any questions that are to be decided by the West of England Combined Authority are to be decided by a majority of the members present and voting, subject to that majority including the vote of the Mayor, unless otherwise set out in legislation, or specifically delegated through the Authority's Constitution. 6. This agreement continues to recognise the importance of the LEP and the private sector in the design and delivery of the area’s economic growth strategies. As such the West of England Combined Authority Mayor will be a member of the LEP. 7. Any transfer to the West of England Combined Authority of existing powers or resources currently held by the constituent authorities must be by agreement with the relevant authorities, as set out in this document.

Fiscal 8. The West of England Combined Authority will create a Single Investment Fund to deliver an ambitious investment programme across the Combined Authority region to unlock the economic potential of the West of England. The West of England Combined

Authority commits to creating and investing in the Single Investment Fund and prioritising investment based on economic impact. To support this investment approach, government agrees to allocate an additional £30 million per annum of funding for 30 years (50% capital and 50% revenue), which will form part of and maintain the West of England Combined Authority single pot. The fund will be subject to 5-yearly gateway assessments. 9. The government will work with the West of England Combined Authority to agree specific funding flexibilities. The joint ambition will be to give the West of England Combined Authority a single pot to invest in its economic growth. This pot will comprise a flexible, multi-year settlement providing the freedom to deliver its growth priorities, including the ability to re-direct funding to reflect changing priorities, whilst upholding their statutory duties. This local freedom will be over a range of budgets to be determined by the West of England Combined Authority and the government shortly. The Combined Authority will have the flexibility to secure substantial private and public sector leverage. The Combined Authority will also be able to use capital receipts from asset sales as revenue funding for public service transformational initiatives. The government expects to disburse this agreed settlement to the West of England Combined Authority annually in advance. 10. The government commits to discuss the business rates appeals system and general appeals process with the West of England Combined Authority to help ensure the West of England Combined Authority is prepared for ongoing developments within the Business Rates system. The West of England Combined Authority will continue to discuss with the government the proposed business rate reforms and how it will affect the city region. 11. The government will give the West of England Combined Authority Mayor the power to place a supplement on business rates to fund infrastructure, with the agreement of the local business community through the local enterprise partnership, up to a cap of 2p per pound of rateable value. 12. As part of the Bristol and West of England City Deal (agreed in 2012) the government supported the creation of an Economic Development Fund with funding provided by the retention of Business Rates from the Temple Quarter Enterprise Zone and the five West of England Enterprise Areas. To enable the ongoing success of this fund the Enterprise Zone and Enterprise Areas will continue to enjoy their current benefits. These include for the Temple Quarter Enterprise Zone and agreed extension to new sites in Bristol, Bath and Somer Valley Enterprise Zone branding and business rates discounts for business moving onto the zone. The Enterprise Zone and Enterprise Areas will also continue to benefit from 100% growth of business rates retention (from the agreed baseline) for 25 years from their designation with 100% protection from any future reset or redistribution.

Skills (19+) 13. The government will enable local commissioning of outcomes to be achieved from the 19+ Adult Education Budget in academic year 2017/18; and will fully devolve budgets

to the West of England Combined Authority from academic year 2018/19 (subject to readiness conditions). These arrangements do not cover apprenticeships. 14. Devolution will proceed in two stages, across the next three academic years: a. Starting now the West of England Combined Authority will begin to prepare for local commissioning. For the 2017/18 academic year, and following the area review, government will work with the West of England Combined Authority to vary the block grant allocations made to providers, within an agreed framework. b. From 2018/19, there will be full devolution of funding. The West of England Combined Authority will be responsible for allocations to providers and the outcomes to be achieved, consistent with statutory entitlements. Government will not seek to second guess these decisions, but it will set proportionate requirements about outcome information to be collected in order to allow students to make informed choices. A funding formula for calculating the size of the grant to local / combined authorities will need to take into account a range of demographic, educational and labour market factors. 15. The readiness conditions for full devolution are that: a. Parliament has legislated to enable transfer to local authorities of the current statutory duties on the Secretary of State to secure appropriate facilities for further education for adults from this budget and for provision to be free in certain circumstances. b. Completion of the Area Review process leading to a sustainable provider base. c. After the area-reviews are complete, agreed arrangements are in place between central government and the Combined Authority to ensure that devolved funding decisions take account of the need to maintain a sustainable and financially viable 16+ provider base. d. Clear principles and arrangements have been agreed between central government and the West of England Combined Authority for sharing financial risk and managing failure of 16+ providers, reflecting the balance of devolved and national interest and protecting the taxpayer from unnecessary expenditure and liabilities. e. Learner protection and minimum standards arrangements are agreed. f. Funding and provider management arrangements, including securing financial assurance, are agreed in a way that minimises costs and maximises consistency and transparency. 16. The Department for Business, Innovation and Skills and the West of England Combined Authority will discuss how the Advanced Learner Loans system can best support more residents to progress to Level 3+, and better meet the needs of the local labour market. 17. The West of England Combined Authority will assume responsibility for the Apprenticeship Grant for Employers (AGE). The AGE funding must be used alongside mainstream apprenticeship participation funding to incentivise employers to offer apprenticeships, but the West of England Combined Authority are free to vary the criteria associated with the grant (e.g. size and sector of business) to meet local needs.

The Skills Funding Agency will work with the West of England Combined Authority to identify an appropriate share.

Skills (16-18) 18. The government will work with the West of England Combined Authority to ensure that local priorities are fed into the provision of careers advice, such that it is employer- led, integrated and meets local needs. In particular, the West of England Combined Authority will ensure that local priorities are fed into provision through direct involvement and collaboration with government in the design of local careers and enterprise provision for all ages, including collaboration on the work of the Careers and Enterprise Company and the National Careers Service.

Employment 19. The West of England Combined Authority will work with DWP to co-design the new National Work and Health Programme designed to focus on those with a health condition or disability and the very long term unemployed. 20. The respective roles of DWP and the West of England Combined Authority in the co- design will include: a. DWP sets the funding envelope, the West of England Combined Authority can top up if they wish to, but are not required to. b. The West of England Combined Authority will set out how they will join up local public services in order to improve outcomes for this group, particularly how they will work with the Clinical Commissioning Groups/third sector to enable timely health-based support. There will be a particular focus on ensuring the integration of the new programme with local services, in order to ensure that national and local provision works well together, and opportunities for greater integration are identified and levered. c. DWP set the high-level performance framework and will ensure the support appropriately reflects labour market issues. The primary outcomes will be to reduce unemployment and move people into sustained employment. The West of England Combined Authority will have some flexibility to determine specific local outcomes that reflect local labour market priorities, these outcomes should be complementary to the ultimate employment outcome. In determining the local outcome(s) the West of England Combined Authority should work with DWP to take account of the labour market evidence base and articulate how the additional outcome(s) will fit within the wider strategic and economic context and deliver value for money. d. Before delivery commences, DWP and the West of England Combined Authority will set out an agreement covering the respective roles of each party in the delivery and monitoring of the support, including a mechanism by which each party can raise and resolve any concerns that arise.

e. DWP to facilitate protocols for data sharing and transparency by tackling some of the obstacles and developing solutions to enable the West of England Combined Authority to develop a strategic needs assessment for the area. 21. The West of England Combined Authority will co-commission the Work and Health programme with DWP. The respective roles of DWP and the West of England Combined Authority will include: a. DWP sets the contracting arrangements, including contract package areas, but should consider any proposals from the West of England Combined Authority on contract package area geography. b. The West of England Combined Authority will be involved in tender evaluation. c. Providers will be solely accountable to DWP, but DWP and the West of England Combined Authority’s above-mentioned agreement will include a mechanism by which the West of England Combined Authority can escalate to DWP any concerns about provider performance/breaching local agreements and require DWP to take formal contract action where appropriate. 22. Building on the learning from the HYPE programme, the West of England Combined Authority will develop a business case for an innovative pilot to support those who are hardest to help and furthest from the labour market. The business case should set out the evidence to support the proposed pilot, cost and benefits and robust evaluation plans, to enable the proposal to be taken forward as part of the delivery of this agreement, subject to Ministerial approval.

Supporting and attracting business 23. The government will work towards closer cooperation with the city region on trade and investment services, including joint activities with UKTI such as: a. Consultation on services and trade missions within an export plan jointly agreed between UKTI and the Combined Authority. b. Ring-fenced trade services resource within the Combined Authority area. Ring- fenced resource remains subject to departmental budget changes. c. Data sharing where practical and feasible on trade and investment specific to the city-region. d. Taking account of the city region’s approach to smart specialisation, which places emphasis on the support for trade and investment services in specific sub-sectors identified as having exceptional presence in the city region. e. Appropriate information sharing to ensure aligned mutually supporting activity in day to day activity. Commitment from appropriate UKTI Sector Specialists to engage in a regular dialogue and joint working with Invest Bristol & Bath (IBB) sector specialists. f. Joint governance structure for the city region investment strategy, through six- monthly meetings.

g. Explore co-location of inward investment operations with UKTI, making full use of the well-established Engine Shed, a city-regional growth hub. 24. On co-location, the government will review the Inward Investment resource location of regional (IST) staff across the three levels of: Partnership Managers; Business development and Key Account Management teams, currently in 8 locations nationally. The government will also look at options for co-location, under UKTI/IST management, without harming the overall efficiency of the working of the investment model. 25. There will be a strengthened partnership between locally delivered services and UKTI, with a joint governance structure including six-monthly meetings attended by a Director level representative from UKTI and the West of England Combined Authority. These will provide a forum to discuss progress on inward-investment team co-location, and on account management activity by both parties in the region. This structure will wherever possible be used to review key decisions and initiatives planned and/or implemented by both parties, including building a better shared understanding of the inward investment opportunities available in the region. 26. The government will explore what options exist for using a portion of GREAT campaign budget for overseas based activity aligned to City Region sector strengths with delivery managed by UKTI Marketing teams with input from the West of England Combined Authority. This activity should be supported by sector based resource in overseas posts who have been specially briefed to have a strong understanding of the West of England Combined Authority sector strengths. 27. The West of England Combined Authority will work with government and their neighbouring regions to develop a regional co-ordinating function for Foreign Direct Investment (FDI) activities. This will lever the existing capacity of Invest Bristol & Bath and its well established FDI based partnerships with neighbouring areas. 28. The government commits to working with the West of England Combined Authority and local partners to realise the economic potential of the Bristol and Bath Science Park and the Junction 21 Enterprise Area Food Enterprise Zone. 29. The government agrees to continue to develop and deliver, in collaboration with the West of England Combined Authority, the joint programme to drive commercial rollout of superfast broadband, particularly in rural areas of the city region. 30. The government will work with the West of England Combined Authority to support the development of the West of England Growth Hub, so that it joins-up and co- ordinates public, private, third sector, national and local support to ensure new and existing businesses access the help they need to boost their productivity and grow. 31. The West of England will work with partners, including government, to develop a strategic approach to regulatory delivery. To build on the Better Business for All national programme, overcoming regulatory barriers and supporting local priorities for growth and reform.

Energy 32. The government recognises the tidal range of the Severn Estuary has the potential to make a significant contribution to the UK’s electricity generation from an indigenous renewable source. The government has launched a review to assess the strategic case for tidal lagoons and whether they could represent value for money for the consumer. The government welcomes the West of England establishing cross-regional governance (in conjunction with South Wales) responsible for developing a Severn Estuary and Bristol Channel Energy Strategy.

European funding 33. The government is committed to working with the West of England Combined Authority to achieve Intermediate Body status for the European Regional Development Fund and European Social Fund. The government will work with the West of England Combined Authority to agree how to delegate powers to select projects on the basis of strategic fit with operational programmes and local conditions. This will allow the West of England to integrate and align investments with other aspects of the devolution deal, to select projects for investment, to improve performance and maximise economic impact.

Housing and planning 34. The West of England is committed to the delivery of high quality, planned, sustainable growth and is leading the way on a strategic approach to regional planning through its emerging Joint Spatial Plan (JSP) and Joint Transport Plan (JTP). 35. The West of England Combined Authority will set an ambitious target for delivering new homes which will be supported by the planning powers detailed below. The housing target will be set out in the West of England Joint Spatial Plan for the period from 2016 to 2036. The West of England will bring forward the Joint Spatial Plan for submission in summer 2017 and this will be subject to an examination in public to ensure it is sound being and undertaken by an independent inspector appointed by the Secretary of State in accordance with the National Planning Policy Framework. 36. The West of England authorities will bring forward a Joint Transport Plan by the end of 2017 followed by a strategic infrastructure delivery plan which identifies infrastructure needed to deal with both the current deficit and Joint Spatial Plan generated requirements, and proposals to fund this through devolved infrastructure funds and other appropriate programmes. 37. The West of England Combined Authority will work with government and its agencies to co-invest in new homes, accelerating the unlocking of barriers to growth, and plan and prioritise investment in associated infrastructure (including transport, schools and health). 38. The Joint Spatial Plan will provide the higher level strategic planning policy framework for each Unitary Authority’s local plan reviews. All planning authorities in the West of

England commit to bringing forward up to date Local Plans in line with this overall strategic framework. 39. The Secretary of State for Communities and Local Government will acknowledge the weight of the West of England Joint Strategic Plan and the four respective local plans as the basis of a comprehensive plan-led approach. The Secretary of State for Communities and Local Government will assist, where possible, in streamlining planning processes so that once the Joint Strategic Plan is in place Local Plans can be rapidly adopted. 40. To improve public confidence in both strategic planning and the planning delivery system for sustainable growth, the government will work with the West of England Combined Authority to enable a strategic approach to a five year housing supply. This would support local authorities when resisting speculative development appeals. 41. The West of England Combined Authority Mayor will exercise strategic planning powers to support and accelerate these ambitions. These will include powers to: a. Adopt a statutory spatial development strategy, which will act as the framework for managing planning across the West of England region, and for the future development of Local Plans. The spatial framework will need to be approved by unanimous vote of the members appointed by constituent councils of the Combined Authority. b. Create supplementary planning documents and a single viability appraisal process, subject to the approval process in paragraph 41a. c. Be consulted on and/or call-in planning applications identified as being of potential strategic importance in the West of England. d. Prepare, submit and determine planning applications for agreed schemes. e. Undertake land assembly and compulsory purchase; and to form joint ventures with landowners, developers and Registered Providers. f. Create Mayoral Development Corporations, with planning and land assembly powers, which will support delivery of strategic sites in the West of England region. This power will be exercised with the consent of the appropriate Members in which the development corporation is to be used. 42. To support delivery of these commitments the West of England Combined Authority and government agree to: a. Review all land and property (including surplus property and land) held by the public sector to better enable strategic infrastructure and housing priorities to be realised. b. The government will work with the West England to support the operation of the Joint Assets Board, and support better coordination on asset sales. This will include ensuring the representation of senior HMG officials on the Joint Assets Board, using that Board to develop as far as possible and consistent with the government’s overall public sector land target, a joint programme of public sector asset disposal. The Joint Assets Board will identify barriers to delivery and develop solutions to address those barriers to help the West of England Combined

Authority meet its housing goals and to unlock more land for employment use. c. A strong partnership to support key large housing sites (1,500 homes +) and joint action to deliver early on starter homes. The government and associated agencies will work in partnership with the area’s local authorities to help resolve barriers with utility companies or government agencies, and invest in suitable land. The government and the West of England Combined Authority will continue discussions on the principle of securing longer term frameworks for funding of key sites, subject to the development of a full business case, meeting our value for money and other funding criteria. 43. Support the West of England in the development of proposals for ambitious reforms in the way that planning services are delivered, and which could enable greater flexibility in the way that fees are set, with a particular focus on proposals which can streamline the process for applicants and accelerate decision making.

Transport 44. The directly elected Mayor of the West of England will: a. Take responsibility for a devolved and consolidated local transport budget, with a multi-year settlement. Functions will be devolved to the Combined Authority accordingly, to be exercised by the Mayor. b. Have the ability to franchise bus services in the city region, subject to necessary legislation and local consultation. This will be enabled through a specific Buses Bill which will provide for the necessary functions to be devolved. This will support the Combined Authority’s ambitions in delivering a high quality bus network and in enhancing the local bus offer. This includes the delivery of smart and integrated ticketing, local branding and provision of minimum standards across the network. c. Take responsibility for a Key Route Network of local roads, which will be defined and agreed by the constituent local authorities, and will be managed and maintained at a city region level, by conferring highway and traffic management powers on the Combined Authority once it is in place. The management, maintenance and improvement of the Key Route Network will be supported by devolving all relevant local roads maintenance funding as part of the Mayor’s consolidated, multi-year local transport budget. This will also support the delivery of a single asset management plan for the local authority network across the Combined Authority area, and streamlined contractual and delivery arrangements. 45. In addition and as part of the deal: a. In establishing the Combined Authority, appropriate2 local transport functions will be conferred to the Combined Authority and exercised by the Mayor. In

2 In establishing the Combined Authority, responsibility for an area-wide local transport plan, public transport functions and the Key Route Network part of the local authority road network will be conferred to the Combined Authority and exercised by the Mayor.

addition, a new single policy and delivery body will be created covering the same area in order to determine, manage and deliver the Mayor's transport plans and the delivery of an integrated public transport network for the city region. b. To support better integration between local and national networks, the government and the West of England Combined Authority will enter into joint working arrangements with Highways England and Network Rail on operations, maintenance and local investment through a new Memorandum of Understanding. c. The West of England Combined Authority will bring forward alternative proposals for the management of current and new rail stations in the Combined Authority area (i.e. the areas of the constituent councils). If any of these proposals would lead to the transfer of any rail station or infrastructure assets to the Combined Authority, the Combined Authority will be obliged to bring forward a business case for consideration by the government. d. The Combined Authority Shadow Board will bring forward proposals that would enable the Mayor and Combined Authority to implement Clean Air Zones in the Combined Authority area. This will help achieve Air Quality Plan objectives at both the national and local level. e. The government will work with the West of England Combined Authority to establish any appropriate local traffic and highway powers to be conferred on to the Mayor as part of the Key Route Network.

Under this geography 46. The Mayor for the West of England will be elected by the local government electors for the areas of the constituent councils of the West of England Combined Authority. The West of England Mayor and West of England Combined Authority will exercise the powers and responsibilities described in this document in relation to its area, i.e. the area of the constituent councils of the West of England Combined Authority. 47. Additional funding or budgets that are devolved as a result of this agreement will go to the West of England Combined Authority, to be exercised by the West of England Mayor or Combined Authority as set out in this document. 48. The West of England Combined Authority must exercise functions in relation to its geographical area. 49. Under the West of England Mayor model, it is not expected that the role of the LEP or private sector would be lessened.

West of England Combined Authority commitments 50. The West of England Combined Authority is accountable to local people for the successful implementation of the devolution deal; consequently, the government expects the West of England Combined Authority to monitor and evaluate their deal in order to demonstrate and report on progress. The Cities and Local Growth Unit will

work with the West of England Combined Authority to agree a monitoring and evaluation framework that meets local needs and helps to support future learning. 51. The West of England Combined Authority will be required to evaluate the additional £30 million per annum of funding for 30 years, which will form part of and capitalise the West of England Combined Authority single pot. The £30 million per annum fund will be subject to: a. Gateway assessments for the £30 million per annum scheme. The West of England Combined Authority and the government will jointly commission an independent assessment of the economic benefits and economic impact of the investments made under the scheme, including whether the projects have been delivered on time and to budget. This assessment will be funded by the West of England Combined Authority, but agreed at the outset with the government, and will take place every five years. The next five year tranche of funding will be unlocked if the government is satisfied that the independent assessment shows the investment to have met the objectives and contributed to national growth. b. The gateway assessment should be consistent with the HM Treasury Green Book, which sets out the framework for evaluation of all policies and programmes, and where relevant with the more detailed transport cost-benefit analysis guidance issued by the Department for Transport (DfT). The assessment should also take into account the latest developments in economic evaluation methodology. c. The government would expect the assessment to show the activity funded through the scheme represents better value for money than comparable projects, defined in terms of a Benefit to Cost ratio. 52. The West of England Combined Authority will work with the government to develop a full implementation plan, covering each policy agreed in this deal, to be completed ahead of implementation. This plan will include the timing and proposed approach for monitoring and evaluation of each policy and should be approved by the DCLG Accounting Officer. 53. The West of England Combined Authority will agree overall borrowing limits and capitalisation limits with the government and have formal agreement to engage on forecasting. The West of England Combined Authority will also provide information, explanation and assistance to the Office for Budget Responsibility where such information would assist in meeting their duty to produce economic and fiscal forecasts for the UK economy. 54. The West of England Combined Authority will agree a process to manage local financial risk relevant to these proposals and will jointly develop written agreements with the government on every devolved power or fund to agree accountability between local and national bodies on the basis of the principles set out in this document. 55. The West of England Combined Authority will continue to adhere to their public sector equality duties, for both existing and newly devolved responsibilities.

Report from West of England Academic Health Science Network Board, 2 March 2016 1. Purpose

This is the eleventh quarterly report for the Boards of the member organisations of the West of England Academic Health Science Network. Board papers are posted on our website www.weahsn.net for information. 2. Business Plan 2016/17

We won’t know our financial allocation for 2016/17 before the end of March, but are working on the basis that most of the work will be a continuation of our current, well supported programmes.

At this stage it seems that new projects will include:

• A second phase of our popular crowd sourcing project “DesignTogether, Live Better” – this time with a distinctly digital flavour. The kick-off event “The Wisdom of the Crowd” on 19 April 2016 is filling up fast. Contact Nada for more information – [email protected] • Avoidable mortality - our Acute Trusts are keen to work together on mortality reviews, sharing good practice. We will support this and bring patient contributors and primary care colleagues into the collaboration. • Health Education South West are funding us to coordinate their new, grassroots approach to developing new models of care and addressing workforce issues in GP practice and wider primary, community and social care. This helps us to build on our primary care support to commissioners and our QI /patient safety work in this setting • Improving wound care – bringing expertise and innovation from the Welsh Wound Improvement Centre we will be working across district nursing and community nursing in Swindon to support better wound care through quality improvement and skills development. A couple of strategic developments in this year’s Business Plan discussions are:

• We have had some good discussions with chairs, CEOs and clinical leaders about how we might support West of England organisations to develop a combined approach to rapid implementation of product innovation and service improvement. Two angles on the same process we think. • How the AHSN can best support effective Sustainability and Transformation Plans – we’ve had lots of feedback that people value what we do now, would like more signposting towards best practice and would like further conversation about how far to change our approach towards community wide working. It was good to hear that senior leaders are happy with how we’re doing things now.

Page 1 of 2 3. Highlights and next steps from our work streams

We continue to report very high levels of momentum in our work and this is because we have huge levels of engagement from commissioners, providers, our Universities and wider partners:

• Diabetes Digital Coach Test Bed: after the celebrations at winning this high profile national competition we are now getting to grips with governance and making clear arrangements for this 27 month experiment with our member organisations and the companies. We will report progress quarterly and have learning events so everyone can join in. • Health Innovators programme – the second programme is running in the first and second weeks of March with 16 participants who want to learn how to turn their entrepreneurial ideas into viable business cases. • ‘Don’t Wait to Anti Coagulate,’ our stroke prevention programme was scored by the other 14 AHSNs as the top adoption and spread project and one that they would be willing to adopt. We now have baseline results from 18 GP practices in Gloucestershire and are on track to save 90 people from having a stroke. People in Bristol will be the next to benefit as Bristol CCG takes this on in 2016/17. • The Health Foundation have accredited us as the third Flow Academy in England joining Sheffield and South Warwickshire in being able to train flow coaches. RUH are working on 3 pathways and will share their learning. • All 7 CCGs are inviting GP practices to volunteer for a primary care patient safety collaborative which will work initially on incident reporting. • The Emergency Department safety checklist is in great demand and has impressive results. We are supporting all the EDs in the West of England to implement it through a collaborative approach. Colleagues from all over the country have asked to use it and we are running a masterclass on 25 April 2016 for all comers. • March is the first birthday for our project to spot and treat deteriorating patients quickly. Every commissioner and provider in the West of England is active in this work to use the National/Early Warning Score across every single interface of care and SWAST are at the heart of this work. • We held a very successful informatics event on 23 February 2016 which included a meeting of the Chief Clinical Information Officers network. The AHSN is supporting health community Digital Road Map events. • Our Evidence and Evaluation Toolkits will be published on their own websites on 22 March 2016 and we warmly encourage you to use them and give us feedback. We will also offer a free two hour workshop on each of “Finding the Evidence” and “Getting started with Service Evaluation” to complement the toolkits in every CCG over the next 3 months. • We continue to support the implementation of the West of England Genomics Medical Centre by leading the Public and Patient Involvement Steering Group and contributing to other work streams such as the education and training Steering Group. We supported the UWE bid to run the Genomics MSc which has now been awarded to Exeter University. 4. Find out more Our e-newsletter is out click on: http://us8.campaignarchive1.com/?u=f0307060daac60c96aab19b07&id=457348f4c7&e= 57daf01a1b

Deborah Evans, March 2016 Page 2 of 2

Report to: Trust Board Agenda item: 8 Date of Meeting: 31st March 2016

Report Title: Executive & Non-Executive Director Walkround Programme Update Status: Information Discussion Assurance Approval X X Prepared by: Sarah Harwood, Compliance Manager & Paul Cresswell, Associate Director of Quality Governance Executive Sponsor (presenting): Sue Jones, Director of Nursing & Quality Appendices (list if applicable): Appendix A – Key Learning Points Appendix B – Actions Arising Appendix C – Exec & NED Walkround Forward Schedules Appendix D – Example of 2 Recent Completed Walkrounds (Exec & NED)

Recommendation:

The Trust Board is recommended to review the latest position and findings on the programme of Executive and Non-Executive Walkrounds completed between December 2015 – March 2016. These were first reviewed at the Quality & Risk Management Committee on 21st March 2016.

North Bristol NHS Trust 1. Purpose 1.1. To provide a summary of the Executive Walkrounds 3. Walkrounds - Summary 2015-16 undertaken in 2015-16 and to provide an update on Table of Executive Walkrounds 2015-16 findings. QRMC Ward/Area Dir Specialty Date Exec 1.2. To provide a summary of the Non-Executive (NED) Jul-15 27B MED Respiratory 05/05/2015 CP Walkrounds undertaken in 2015-16 and to provide an Jul-15 28B MED Care of the Elderly 26/05/2015 SW update on findings. Jul-15 G20 CCS Theatres (Emergency) 08/06/2015 CP Sep-15 G21 CCS Theatres (Elective) 29/06/2015 CP Sep-15 7B MSK Orthopaedics 22/07/2015 SW 2. Background Jan-16 G35 MED MIU 18/08/2015 SK 2.1. Executive Walkrounds are a long-standing activity for Jan-16 G37 CCS ICU 08/10/2015 SW the Trust, however since early 2015 we have Jan-16 Quantock WCH Maternity 12/10/2015 SW Jan-16 8B RTO Renal 19/10/2015 CB strengthened the way these are reported and Jan-16 Cotswold WCH Gynae 30/10/2015 SJ/PJ consequent actions are carried out. We have also Jan-16 G5 MED Medical Day Care & 03/11/2015 PJ improved the number completed, ensuring these are Chemo Suite spread more evenly among the Executive team than Jan-16 31A&B MED AMU 10/11/2015 CP had historically been the case. At the last QRMC in Jan-16 34A SUR Colorectal, Upper GI 12/11/2015 SJ January 2016 the importance of Executive visibility Jan-16 33A SUR Burns & Plastics 27/11/2015 KH was re-emphasised and it was agreed that Jan-16 Riverside WCH CAMHS 04/12/2015 AY Executives would complete one walkround every 2 NEW Elgar 2 MED Rehab 08/01/2016 CB months (i.e. 6 each per year). NEW IR CCS Imaging (& flow 20/01/2016 SJ pressures) 2.2. Since agreement in early 2015 that the NEDs should NEW Discharge OPS 20/01/2016 SJ also be involved in a walkround programme of their Lounge own they have been trialling the “15 Step Challenge”. NEW 25A NEUR Neurology, Neurosurgery 12/02/2016 PJ This is a tool that focuses on care from the patient NEW Birth Suite WCH Maternity 15/02/2016 CB NEW Percy Phillips WCH Maternity 15/02/2016 ND perspective and gives the NED chance to have open NEW Rosa Burden NEUR Neuropsychiatry 29/02/2016 SW discussions with the ward sister, matron and patients TOTAL: 22 and relatives. At the Board in February 2016, the

continuation of NED walkrounds using 15 Steps was confirmed. It was agreed that each NED would now complete 2 walkrounds per year.

QRMC Ward/Area Dir Specialty Date NED 2016-17 against their availability and to visit any Jul-15 27A MED Cardiology 17/04/2015 RM particular areas of stated interest. Jul-15 CDS WCH Maternity 15/07/2015 AW Sep-15 Quantock WCH Maternity 12/08/2015 LR 4.6. Both Executive and NED Walkrounds have a forward Sep-15 G5 MED Medical Day Care & 14/08/2015 PR schedule for the year, as shown in Appendix C. Chemo Suite Jan-16 7A NRO Stroke 14/09/2015 RM 4.7. Examples of one completed Executive Walkround and Jan-16 26B SUR Surgical Short Stay 01/12/2015 KG one completed NED Walkround are shown in full in Appendix D NEW NICU WCH Neonatal Medicine 16/02/2016 NC TOTAL: 7 5. Recommendations

4. Summary 5.1 To review the latest position and findings from the Walkround programme. 4.1. Since the last review at the QRMC in January, 7 5.2 To suggest any ways in which the Board would like to Executive Walkrounds have been carried out, producing see this information presented in future. rich qualitative information containing great examples of 5.3 To consider how actions ‘assigned’ to Executives can be care, as well as some for improvement. A summary of best progressed following the Walkround and fed back to the findings from the recent walkrounds and the actions staff within the area concerned. arising are shown in Appendices A & B. 4.2. The walkround schedule will be monitored closely to ensure this level of activity is maintained.

4.3. In all the Executive walkrounds, no key concerns

requiring immediate escalation to the Head of Nursing

were reported.

4.4. Copies of completed Walkrounds and the action plans will shortly be available on the Trust intranet. 4.5. The Risk and Compliance Team have contacted our NEDs and established a forward schedule for the rest of

Appendix A

Latest Executive & NED Walkrounds (December 2015 – March 2016) – Key Findings

Ward/area Exec Most positive Most negative 33A KH (Awaiting form) 26B (NED) KG  Overall impression very good. Spoke to 2 patients – care on  Shortages of drip stands / pillows etc. Ward very good.  External area was unmanned, what is its purpose?  Air flow issue to be raised with Facilities. Elgar 2 CB  Different activities e.g. stretching, balancing, bowling, bingo There is a shortage of wheelchairs on the ward. are being planned around meal times to keep patients active. At the end of March NBT staff will be TUPEd to Sirona, but there is a lot of stress The ward are also working with the Fresh Arts team who have amongst the staff as worried about pension, holidays, sickness. Two meetings provided doodling and colouring books for patients. held before Christmas with HR, Sirona and the projects team, but nothing further Sister is currently acting into the band 7 post and felt that has been discussed since. Staff are beginning to look for other jobs in other areas. setting up the new system was really exciting. Sirona staff have There is no written information for patients and relatives when they are been really helpful. discharged to say who to contact if they have any problems, or who is looking after them. This would be useful. IR SJ (Awaiting form) Discharge SJ (Awaiting form) Lounge 25A PJ Patient very complimentary about the nursing staff and Junior  Physio don’t have resources for patients with head and spine injuries. Doctors in particular.  Staff being asked to be sent down ED which leaves the ward short.  Good place to work, students on placement return to the ward. Birth Suite CB Positive feedback has been received about the unit and there is  Statistics for when the staff are called upon to work on CDS and normal service a birthing pool on order for room A3, which will mean all 3 rooms on the birth suite is not available were at 19% for last month, which equates to have a birthing pool. 1.5wte, and 13% for this month. Support from community midwives and health visitors is good. There is an issue with night time cleaning. During the day cleaning is very good, The unit would like to push for it to be the default unit for all but at night the MCA’s do the cleaning. This has put morale at a low as they spend women to attend first before going to the central delivery suite, a lot of time cleaning. A 24-hour cleaner would be better. These MCA’s are which is in line with the national way forward. expected to do the cleaning and stocking, which can interrupt part of their NVQ curriculum. Percy Phillips ND The Nursery Nurses do a fantastic job to support the Ward, One of the Bathrooms (near the bays for transitional care babies) is in an particularly in relation to Transitional care. appalling condition and needs renovation. Patient Flow Midwives are very valuable There is an issue with getting larger dosage of Clexane of the higher BMI women. Staff, particularly those on rotation, do not want to leave. Current shortage of nurses and high sickness rate.

This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under a 'closed section' of any meeting. 4 North Bristol NHS Trust NICU (NED) NC  The Matron and Sister have very good control of the Ward.  The parent bedrooms are very basic and could be made more comfortable - the  Staff are working very well with limited resource. Trust may want to look at updating facilities.  Very passionate staff who work well together.  One potential health and safety risk observed in that 4 breast pump machines were stored/left in front of one of the fire extinguishers in the Unit. Although the Unit is tight for space an alternative storage point needs to be identified. Rosa Burden SW (Awaiting form)

Latest Executive Walkrounds (December 2015 – March 2016) – Actions Arising

Action Responsibility Ward Visited Action Executive Ward Who Contact wheelchair services to see if they can help with wheelchair provision / repairs  Chris Burton Elgar 2 Find out about information leaflets for patient discharge (Gill Brook)  25A Feedback to Sue Jones re staffing in ED  Paul Jones Rachel to look further into how St Michael’s resolved their problem with MCA’s cleaning at  night Rachel to look into getting statistics for when the unit is unable to operate as staff are being Birth Suite  used elsewhere. Work to be done to encourage more women to pick the Birth Suite as their first choice for  delivery when possible Percy Phillips Enquire with IT whether the copier/scanner can be networked to the PCs  Neil Darvill

Appendix C – Executive and NED Walkround Forward Schedules

Executive Walkround 2016 Schedule - 1 w/r each, every 2 months Executive Jan/Feb Mar/Apr May/Jun Jul/Aug Sep/Oct Nov/Dec Chris Burton Elgar 2 & Birth 6B 33A 9B Suite Neil Darvill Percy Phillips HITU 27B 25B Enablement BCRM Services Kate Hannam 32B Paul Jones 25A NICU Sue Jones IR & Discharge 27A & 7B ED Lounge Outpatient Therapies Catherine Phillips - Antenatal Clinic G21 Theatres G20 Theatres Simon Wood Rosa Burden 8B

Andrea Young - Mortuary, 9A 26A 33B CDS & Elgar 1 & 2 Cossham Birth Suite

NED Walkround Schedule 2016-17 - 2 each per year 1 2 John Everitt Apr-16 G20 Theatres Nov-16 34B Rob Mould May-16 AMU Dec-16 9A Cossham - Outpts Liz Redfern Jun-16 34A Jan-17 & Dialysis Peter Rilett Jul-16 27A Feb-17 ED Andy Willis Aug-16 G13 Feb-17 28B Ken Guy* Sep-16 Mendip Mar-17 6B Nishan Canagarajah Oct-16 32A Mar-17 8B

*End of NED term March 16 – will contact replacement once appointed.

Executive Walkround

Ward / Clinical Area Elgar 2 Date & Time 8th January 2016 at 11.00 am Executive Chris Burton

Executive Observations Good Practice Concerns With effect from 1st April 2016 the ward There is a shortage of wheelchairs on the will go over to the care of Sirona ward. This makes it difficult for relatives to take the patient anywhere, other than the There are 2 GPs, on locum contract, who ward. spend 2 days each on the wards. This is a new role and still in the early stages. The one wheelchair that is on the ward has a broken brake. This week there were extra therapists on the ward and this had helped to expedite Therapists also need wheelchairs for discharges, including on Saturday. The patient care. service was not yet available on Sunday, but this is currently being investigated. Unable to view the patient details on the white board as the system was not working There are 34 beds on the ward. properly.

There is a dining area, where they hope The ward currently have 37 patients. All to encourage patients to sit, which also patients are referenced through JCAP has a TV. Different activities e.g. before being assessed for the D2A stretching, balancing, bowling, bingo are pathway. It was unclear as to how the being planned around meal times to keep Bristol patient had been accepted onto the patients active. This is being arranged ward. by the therapists.

The ward are also working with the Fresh Arts team who have provided doodling and colouring books for patients.

Executive Impression (indicate): **    **HELP… Immediate feedback to HoN, and HoN to follow -up / respond to issues within 1 week

Discussions with Staff

Prompts…

• How’s it going today? • Could you care for your patients this week as safely as possible? • What are you proud of this week? • What are your top three concerns? • How does communication between staff either help or hinder safe care on your ward? • How can we help you to undertake activities that improve safety and patient experience? • Did you discuss with your manager any incidents / complaints that have been reported? • Do you know what happened following the reported incident(s) / complaints? • Is there anything you want to ask me? Do you have any ideas or good practice to share? Good Practice Concerns Staff spoken to (name/role): H

Confirmed that there were sufficient staff At the end of March NBT staff will be on the ward, although there was TUPEd to Sirona, but there is a lot of increased pressure with the 3 extra stress amongst the staff as they are patients. There are 5 trained nurses, and worried about pension, holidays, sickness. 5 HCAs. When there is a patient requiring Two meetings had been held before enhanced care, there are 2 HCAs on the Christmas with HR, Sirona and the bay. projects team, but nothing further has been discussed since. Staff are beginning Sirona staff have been really helpful. It is to look for other jobs in other areas. useful to know staff in the community and it helps to make things smoother when There is no written information that can be there are cases of people wanting to go given to patients and relatives when they home, but it is difficult to get packages of are discharged to say who to contact if care in place in time. they have any problems, or who is looking after them. This would be useful. The nursing staff on the ward are all NBT staff and the therapies staff are from Sirona.

H is currently acting into the band 7 post and felt that setting up the new system was really exciting.

She had been to other areas run by Sirona and noted that staff here all seemed to be very happy and friendly.

Discharge dates for patients are set early and patients usually go home on the date stated, sometimes earlier. The therapists are very good at setting the dates.

Good Practice Concerns Staff spoken to (name/role): R R is the Therapy lead. The three extra beds put on the ward had The therapy team, 8wte, are all new to the caused issues, especially as one was ward and started this week. They have from the Bristol area, which would be come from backgrounds such as rehab difficult to get the patient discharged and care homes. There will be a through South Glos. rotational post amongst these. These staff are all used to treating patients in Issues with stroke patients taking longer their own homes and are fully aware of to get home, noted that these staff are expectations and risks to be managed. working differently.

R is trying to set up a new ethos on the ward, that home is best.

Rnoted that she was happy working for Sirona. She would be encouraging NBT staff to move across to Sirona.

CB queried how the ward was working from a patient perspective. There is still a lot of work to be done to get everything in order, including work spaces, but this is work in progress and everyone is keen to help.

R is confident that patients will be discharged as soon as care in the community will allow. Support workers are now in post and have changed their working hours to fit in with acute discharges.

R keen to work with the therapists and invest in some people skills.

Staff spoken to (name/role): J J was happy that Sirona have delivered CHC fast track can cause delays, what they said they were going to deliver. especially if the patient wants to stay at Flow has been good, LoS at an average home, as there is no-one available to of 26 days. deliver the care required. This can be assisted if the patient’s family help to care Package of care will depend on how for the patient. quickly patients can be discharged into the community. If it is only a once a day Community care in the area is in deficit, visit then these go through quickly, but also patients don’t always want to accept once the care requirements are for more the offer of care homes. visits this will slow the process.

Possibly looking to move to the GPSI Good Practice Concerns model.

S has been excellent in providing ward round cover, and looking to move from using locum SHO to nurse practitioners.

Actions

Any outstanding actions from last Walkround? Yes No N/a

Action Plan To be completed with Sister / Manager in Charge. Executive Ward Actions – to be completed by… (tick) (tick) 1. Contact wheelchair services to see if they can help with wheelchair  provision / repairs. 2. Find out about information leaflets for patient discharge (Gill Brook)  3. 4.

Please now; • ensure the Executive has updated the Ward Visitor Book • type up the findings on a blank template • retain a copy for the Executive, and • send an electronic copy to Ward Sister / Manager in Charge and [email protected], Risk & Compliance Team.

Non-Executive Walkround “15 Steps Challenge”

Area Visited: NICU Comments fed-back to: Nurse in Charge: Michelle Jackson (name and designation) Date: 16 February 2016 Michelle Jackson, Matron and Gill Taylor, Sister Time: 9.30am Non-Executive Director: Nishan Canagarajah PROMPTS TO CONSIDER… WHAT BUILDS TRUST AND CONFIDENCE? WHAT DOESN'T? Welcoming….. Positives Recommendations 1. What can you smell, hear, and see? A clean, calm and organised Unit 2. How does this ward make you feel? Happy, reassured and well looked after A welcoming area although no receptionist 3. Welcoming reception area? present when we arrived 4. Staff make eye contact, smile, and greet you? Yes – very good 5. Is there information in different languages? There is lots of information displayed 6. Is there contact information / visiting times for relatives, visitors? around the Unit Yes, there is a notice board behind 7. Is there info about the staff team and what uniforms mean? Reception 8. Is it accessible to someone with disabilities? Yes 9. Positive interactions between staff / patients? Yes Yes – numerous gel units and sinks are 10. Are hand gels available? also available Safe….. Positive’s Recommendations Information is displayed consistently 11. What tells me that staff are concerned about safety & preventing around the Unit and the ward is clearly harm? signposted CQC board at Reception and plenty of 12. What information tells me about the quality of care here? hand hygiene signs This is an opportunity to display how 13. Can I see information that says the ward is improving? well the unit performs 14. The environment is clean, tidy and well maintained (floors / walls) Yes, very 15. Does equipment appear well maintained? Yes All parents and visitors must pass through One potential health and safety risk 16. Security and fire procedures are evident? Security on the General Maternity Ward observed in that 4 breast pump before they are allowed access onto machines were stored/left in front of NICU. Parents wear purple lanyards and one of the fire extinguishers in the Unit. relatives/visitors wear red ones so they are Although the Unit is tight for space an easily identifiable and all must sign in and alternative storage point needs to be out. identified. Yes, all staff had name badges which 17. Do patients and staff have identity bracelets / name badges? were clearly visible 18. Do patients have access to call bells, drinks, walking aides etc.? Yes 19. Were mealtimes protected? N/A PROMPTS TO CONSIDER… WHAT BUILDS TRUST AND CONFIDENCE? WHAT DOESN'T? Caring and involving….. Positives Recommendations Very good. Parents have access to 4 The parent bedrooms are very basic 20. What can I understand about patient experience on this ward? bedrooms, a kitchen, a family room and and could be made more comfortable there is also a bereavement room Parents are encouraged to provide as 21. Any indicators that patients & carers are involved in their care? much care as they can 22. Info that empowers patients e.g. wear their own clothes, choose meals N/A 23. How is dignity and privacy being respected? Curtains / blinds? There are lots of screens and these are Are patients dressed to protect their dignity? used if procedures are invasive Yes – the Unit has also just purchased 24. Are staff using lower voices for private / patient conversations? some ‘environmental ears’ 25. Can I observe good team working taking place? Yes 26. Is the routine of the ward evident to patients? Yes Yes – there are lots of thank you cards 27. Patient feedback is displayed and drawings located at Reception. No information displayed on how to 28. Information about how to complain and compliment is visible make a complaint Well organised and calm….. Positives Recommendations The Unit felt very calm – although only 23 29. Does the ward feel calm or chaotic (even if busy) cots out of the 34 were in use today (which is unusual) 30. Is essential information about each patient clearly visible? Yes 31. Do staff have easy access to patient information that is visible Yes 32. Stock cupboards are well organised, colour-coded, and Yes and improving – new storage racks on equipment is stored tidily in particular places order Yes The High Dependency Unit is still 33. Clear signage to rooms, WCs displaying signage that refers to Special Care and this needs to be changed General Comments, Headlines, Overall Impression The Matron and Sister have very good control of the Ward. Staff are working very well with limited resource. Very passionate staff who work well together. In future the Trust may look at updating facilities or increased provision for the Unit.

Action required Person Responsible 1 To display information on how the unit is p’erforming and improving (MJ/GT) To address storage issues and ensure that equipment does not block fire 2 extinguishers or pose a health and safety hazard (MJ/GT) To display information on how to submit a complaint/compliment 3 (MJ/GT) (NC to ask ACT to provide) 4 Signage outside High Dependency needs to be updated (MJ/GT)

Report to: Trust Board Committee Agenda item: 9

Date of Meeting: 31st March 2016

Report Title: Integrated Performance Report (IPR)

Status: Information Discussion Assurance Approval

X X x

Prepared by: Ian Triplow, Associate Director of Performance and Sustainability

Executive Sponsor (presenting): Executive Team

Appendices (list if applicable): IPR

Executive Summary Access – The Trust failed to meet the 4 hour standard for A&E, February’s performance at 69% against a target of 95%. Whilst bed pressures continue to be the main source of breaches, the impact of the switch from Cerner to Lorenzo in mid-November continues to impact waiting times in ED.

The Trust exceeded its trajectory for Referral To Treatment incomplete performance overall agreed for 2016/17 at an overall percentage level (89.2% vs target of 86.6%). The growth in over 18 weeks pathways has been offset by a corresponding increase in under 18 week pathways being reviewed as part of the Data Stabilisation work.

The Trust has failed to meet the overall diagnostic target in February (97.32%) due to poor performance in Endoscopy following on from unexpected vacancies

The final position of Cancer targets in December showed the Trust had delivered on 3 of the 8 Cancer waiting targets. The ‘unvalidated’ position currently has the Trust passing 5 of the 8 key targets in January.

North Bristol NHS Trust

Safety - The Falls rate per 1000 bed days was 6.49, under the national average of 6.63. The Trust reported 34 gender breaches in February in the Emergency Department Observational Unit.

Patient experience – Overdue complaints has reduced to 41. Standardised mortality ratios continue to show lower risk of mortality for care in NBT than national benchmarks

Workforce – In February for recruitment there were 152 wte new starters against a target of 110. Vacancy levels have reduced by 40.24 wte on last month. Compliance in January 2016 for overall mandatory training seen a slight increase compared to the previous month.

Finance - For the year to date the Trust has a deficit if £49.1m which is £23.1m adverse to plan. The primary drivers for the adverse to plan were lower than planned contract income of £12.4m together with pay overspends of £7.4m coupled and a non-pay overspend of £3.1m. Additional workforce controls have been introduced to assist the recovery plan actions to reduce agency expenditure and increase elective activity.

V1 1

North Bristol NHS Trust

INTEGRATED PERFORMANCE REPORT

March 2016 (presenting February 2016 data)

XXXX 2 XXXXXExecutive Summary FebruaryBoard Sponsor 2016 XXXX

Access – The Trust failed to meet the 4 hour standard for A&E, February’s performance at 69% against a target of 95%. Whilst bed pressures continue to be the main source of breaches, the impact of the switch from Cerner to Lorenzo in mid-November continues to impact waiting times in ED.

The Trust has failed to meet the overall diagnostic target in February (97.32%) due to poor performance in Endoscopy following on from unexpected vacancies

Safety - The Falls rate per 1000 bed days was 6.49, under the national average of 6.63. The Trust reported 34 gender breaches in February in the Emergency Department Observational Unit.

Patient experience – Overdue complaints has reduced to 41. . Standardised mortality ratios continue to show lower risk of mortality for care in NBT than national benchmarks

KeyCommentary / Notes CQC Domain / Sponsor/s Page XXXX Report Section Number UnlessXXXXX noted on each graph, all dataXXXX shown is for period up to, Responsiveness Director of Operations & Medical 4 and including, 29th February 2016. Director Safety & Effectiveness Medical Director, Director of Nursing, & 17 All data included is correct at the time of publication. Please note Director of Facilities that subsequent validation by clinical teams can alter scores Safe Staffing Director of Nursing 19 retrospectively.

Caring Director of Nursing 34 All target lines: All improvement trajectories: Well Led Director of People & Organisation Health 39

and Medical Director DASHBOARD KEY:

Finance Director of Finance 47 Perf worsened & below target

Regulatory View Chief Executive 53 Perf worsened, but above target

Perf worsened, no target Annual Calendar n/a 56 Perf improved but below target

Perf improved & above target

Perf improved, no target

Directorate/Group Abbreviation Glossary Perf stayed same, below target CCS Core Clinical Services Non Cons Non-Consultant CEO Chief Executive Ops Operations Perf stayed same , above target Clin Gov Clinical Governance Renal Renal Transplant & Outpatients IM&T Information Management Surg Surgery Perf stayed same , no target Med Medicine W&Ch Women’s & Children’s MSK Musculoskeletal

XXXXRESPONSIVENESS 4 XXXXXSRO Kate Hannam Director of Operations Board Sponsor XXXX

Overview

Urgent Care February’s 4 hour A&E performance was 69% against a target of 95%. Whilst bed pressures continue to be the main source of breaches, the impact of the switch from Cerner to Lorenzo in mid November continues to impact waiting times in ED. Process mapping and system redesign is underway by IT and the ED team to reduce the on-going impact, but is not expected to deliver until April 2016. Before the Trust can confirm it’s 2016/17 trajectory capacity and demand refresh of community plans, agreement on NEL growth, plus our own in house bed modelling; are required actions. A 6 week internal rapid improvement programme has been launched in mid March and additional clinical and management resource allocated. The programme will seek to embed within existing directorate structures in the longer term.

RTT Trust RTT performance overall is within the RTT improvement trajectory agreed for 2016/17 at an overall percentage level (89.2% vs target of 86.6%) but the impact of data quality issues caused by stabilisation issues with Lorenzo and in particular poor compliance with SOPs, issues with the initial training, the lack of reports / availability to manage the process as well as operational difficulties adapting to the new system have: (1) inflated our under 18 week incomplete pathways Oct 2015, 25,010 pathways under 18 weeks vs. 40,423 pathways under 18 weeks as of February 2016, (2) reduced booking efficiency of the NADM pathway which has inflated the over 18 week backlog number and once DQ issues are corrected will be a risk to performance going forward.

DQ Mitigation plans have been agreed via the Lorenzo Operational Board and are being monitored via the Stabilisation plan. Clinical Directorates will need to replace December and January’s lost capacity between now and May. Operational issues not associated with Lorenzo i.e. February’s spike in same day cancellations (2.7% vs 0.8% target) due to bed pressures as well as growth in NEL activity has reduced admitted elective work since the new year and contributed to expansion of backlogs in T&O (non-Spinal), Urology and General Surgery. Mitigation plans have but the Trust is unlikely to meet the initial backlog patient target and the overall percentage performance will be dependent on the pace of the DQ stabilisation project. The Trust remains on trajectory for clearance of the 52 week breaches in Orthopaedic Spines, Neurosurgery and Adult Epilepsy (126 actual vs. target of 158) – the main differential is within Epilepsy due to removal for reasons other than treatment. Areas of Concern The system continues to monitor the effectiveness of all actions being undertaken, with weekly and daily reviews. The main risks identified to the Urgent Care Recovery Plan are as follows: UCRP Risk 4: Lack of community capacity and/ or scope to provide Discharge to Assess pathways to reduce the size of the LHPD. SG and Bristol D2A plans are unlikely to deliver in line with bed model assumptions and mitigation is underway. North Somerset delays have grown in recent months (15% of overall delays) UCRP Risk 5: Appropriate nursing and therapies staffing within NBT to enable flow given vacancy rates and hot spots such as AMU UCRP Risk 6: LoS reductions and bed occupancy targets in the bed model are not met leading to performance issues UCRP New Risk: Weston ED shuts for 7 weekdays and an as yet unspecified number of weekend shifts in April 2016 due to staffing problems related to sustainability issues. Risk of 10-15 extra medical admissions to NBT overnight. Director level system mitigation in discussion at present. ResponsivenessXXXX 5 SummaryXXXXX Dashboard Board SponsorsSponsor XXXX Director of Operations

Most recent February 2016 quarter’s performance Against Trend from Performance Quarterly Trend (Q1 vs Q2) Access Standard national last month to be achieved (Quarter 3 Oct – Dec ) target by… (as per trajectory) against national target Emergency Attendances – waits Not met in under 4 hour standard vs total 69.5% 91.1% (Q1) to 93.4% (Q2) attendances (95% target) 15-16 Referral to Treatment - % incomplete pathways <18 weeks 89.2% n/a 86.1% (Q1) to 86.4% (Q2) (92% target) Referral to Treatment - % within 18 weeks of GP referral for non- 89.6% n/a 93.3% (Q1) to 93.8% (Q2) admitted patients (95% target)

Referral to Treatment - % within 18 Not met in weeks of GP referral for admitted 71.8% 80.3% (Q1) to 81.0% (Q2) patients (90% target) 15-16

Trust wide Referral to Treatment Not met in 4758 3874(Q1) to 3922 (Q2) Backlog 15-16 Cancelled Operations – same day - Not met in 2.8% 1.33% (Q1) to 1.33% (Q2) non-clinical reasons (0.8% target) 15-16 Cancelled Operations – 28 day re- Not met in 21 (Q1) to 12 (Q2) booking breach (0 target) 6 15-16

Please note: Subsequent validation by clinical teams can alter scores retrospectively. Data is correct at time of publication. ResponsivenessXXXX 6 UrgentXXXXX Care Board Sponsor XXXX Director of Operations

Commentary COO01 Urgent Care - Waits in Under 4 hours vs Total Attendances Commentary 17 OverallXXXX February’s performance 100.0% againstXXXXX the 4 hour target 69% with waitingXXXX for a bed being the main 95.0% cause of breaches, followed by 90.0% awaiting ED assessment. During February the Trust has 85.0% predominately been in red or black escalation levels with all escalation 80.0% capacity open (IR and Cotswold) 75.0% reflecting the known bed deficit overall. 70.0% The Internal actions in the Urgent

Percentagepatients of 65.0% Care RAP aim to improve flow through better discharge planning 60.0% and reduce bed occupancy overall. Medically fit for discharge bed days were above plan and spot purchasing by commissioners COO70 Urgent Care – reasons for breaches of 4 hour DON20 Breaches by Day of week 999 remains limited – a system’s standard February - 2016 2500 leaders event to review the Sunday Saturday Friday capacity gap is planned for April to Thursday Wednesday Tuesday inform the 2016/17 business 2000 Monday planning. The switch to Lorenzo continues to cause ED delays resulting in 1500 breaches (esp. within minors). A joint review by the directorate and 1000 IM&T will conclude in April to ED Breaches ED confirm the on-going scope of Lorenzo in ED. 500 A 6 week rapid improvement programme, “Proactive Hospital” Waiting for a bed Awaiting ED commenced on 15th March, initially Clinical Waiting for Diagnositic 0 focused on supporting the medical Waiting for Specialist Other Waiting for Transport wards, but will expand in ED and surgical bed bases by May 2016

XXXXResponsiveness 7 XXXXXPatient Flow Work stream Board Sponsor Sponsor XXXX Director of Operations Commentary Commentary XXXXThe Trust has made sustainable XXXXXprogress against a number of ECIST recommendations but has not benefitted overallXXXX over the winter period due to the high level of bed occupancy and the inability to date to shift discharges to earlier in the day • % of weekend emergency admissions to discharges has been consistently above the ECIST recommended 85% • The AMU/ ambulatory care changes have resulted in us being above the 50% target for new admissions being discharged within 2 midnights

Alongside initiatives to decrease bed occupancy the Proactive Programme will focus on: • Achieving earlier movement out of assessment areas and ED to ensure earlier intervention by senior decision makers and appropriate specialists/ MDT team, thereby ensuring speciality patients move to the right ward • Re-setting specialty level risk parameters for discharge when faced with specialty capacity imbalances • Changes to the Infection control/ cleaning processes, to reduce the bed hours lost overall to the Trust • Integrated Discharge Service – standardise support across all wards as well as reducing the levels of cancellation rates • More effective use of Trust resources i.e. Discharge lounge / Pharmacy etc • Criteria led discharge audit of Surgery usage and re-launch in Medicine planned • Weekend discharge planning XXXXResponsiveness 8 XXXXXLength of Stay and Discharge BoardBoard SponsorSponsor XXXX Director of Operations

COO20 999 LoS Over 14 Days Feb 2016 Commentary Not on MFFD list (Green) and On MFFD (Blue) XXXXAs part of the agreed Internal Flow XXXXXimprovement plan over 10 days 300 XXXXdata is been cross referenced with the electronic white board patient 250 status to ascertain possible

200 internal causes of elongated stays.

150 Modelling of complex discharges

C&D has been undertaken to Discharges 100 inform URCP plans to reduce overall leaving hospital patient 50 database numbers, in light of the disproportionate impact this 0 patient cohort has on occupied bed days. The main cause of MFFD delayed days remains wait for assessment despite the formal introduction of Discharge to Assess pathways – although % levels across localities differs.

In February the total number of medically fit for discharge days was 481 with the majority of the reduction in South Gloucs. Overall MFFD bed occupancy is lower than January 2015 – even when Elgar 2 is included in MFFD numbers. The DTOC level remains above the national target of 3.5%. As yet we are not assured community and social care plans will meet this target across the rest of the year

XXXXResponsiveness 9 XXXXXReferral to Treatment All Specialties Board Sponsor XXXX Director of Operations

Commentary TrustXXXX RTT performance overall is withinXXXXX the RTT improvement trajectory agreed for 2015/16 at an XXXX overall percentage level (89.2% vs target of 86.6%) but the impact of data quality issues caused by poor compliance with Lorenzo SOPs, errors with the initial Lorenzo training, as well as operational difficulties adapting to the new system have: (1) inflated our under 18 week incomplete pathways (2) reduced booking efficiency of the NADM pathway DQ Mitigation plans have been agreed via the LOB. Directorates need to replace December and January’s lost capacity by May. Operational issues not associated with Lorenzo i.e. January and February spike in same day cancellations (2.7% vs 0.8% target) due to bed pressures as well as growth in NEL activity has reduced admitted elective work since the new year and contributed to expansion of ADM backlogs in T&O (non-Spinal), Urology and General surgery. Mitigation plans have but the Trust is unlikely to meet the initial backlog patient target and the overall percentage performance will be dependent on the pace of the DQ stabilisation project. .

ResponsivenessXXXX 10 ReferralXXXXX to Treatment 52 week waits & Diagnostics Board Sponsor XXXXDirector of Operations

DOO058 Commentary 999 Diagnostics 6 week wait Commentary The Trust remains on trajectory for (Orange = Improvement Trajectory) XXXX XXXXXclearance of the 52 week breaches XXXXin Orthopaedic Spines, Neurosurgery and Adult Epilepsy (126 actual vs. target of 158) – the main differential is within Epilepsy due to removal for reasons other than treatment. Orthopaedic Spinal clearance is planned for Q4 of 2016/17, Neurosurgery is Q3 2017/18 and epilepsy is Q3 2017/18.

In January, the Trust overall has failed to meet the diagnostic target in February (97.32%) due to poor performance in Endoscopy. The main issues were consultant level vacancies in surgery and gastro, alongside growth in demand due to early adoption of the NICE cancer standards by GPs. A remedial action plan is in the process of being jointly agreed with commissioners given the demand is at an un-commissioned level The Trust has exhausted all local independent sector options to recover the endoscopy position, Best case sees Endoscopy return to compliance by Q1 2016/17, worst case September 2016/17. Modelling is underway to aggregate the overall Trust impact as a result.

ResponsivenessXXXX 11 ElectiveXXXXX Operations Board Sponsor XXXXDirector of Operations

COO68 COO08 Commentary Urgent Operations Cancelled for 2nd Time 003 Cancelled operations 28 day re-booking breach - Monthly trend in breaches (target is 0) XXXX 7 XXXXXDespite a second month of 14 XXXX 6 high levels of cancellations 12 (2.7% vs. 0.8%) for non- 5 clinical reasons related to the 10 wider flow and bed issues, the 4 8 Trust has maintained it’s 28 3 day re-booking target.

Operations 6 Breaches 2 4 Urgent operations cancelled for the second time was 6 1 2 patients overall. 0 0 Individual mini RCAs are completed each time there is a 28 day re-book and lessons COO09 015 Cancelled Operations (same day - non-clinical Cancelled Ops by Reason are shared across reasons) 160 directorates. 3.0% 140 120 2.5% 100 2.0% 80 60

1.5% CancelledOps 40

Performance 1.0% 20 0 0.5%

0.0% Clinical Emergencies Equipment No Beds Operational Staffing Theatre Time Transport ResponsivenessXXXX 12 CancerXXXXX Summary Dashboard Board Sponsor XXXXDirector of Operations

Jan 16 Q2 February 2016 Performance (Jul – Sept 15) Quarterly Average Trend – Q1 vs Q2 against (un-validated position) Standard Final Jan Against Trend National Target

16 position National from last Target month Feb 16

Patients seen within 2 weeks of an urgent GP 91.3% 94.8% 92.2% (Q1) to 93.5% (in Q2 to date) referral (93% target)

Patients with breast symptoms seen by 85.3% 99.2% 99%(Q1) to 96.9% (in Q2 to date) specialist within 2 weeks (93% target)

Patients receiving first treatment within 31 93.2% 93.6% 89.1% (Q1) to 90.3% (in Q2 to date) days of cancer diagnosis (96% target)

Patients waiting less than 31 days for 90.8% (Q1) to 93.3% (in Q2 to date) subsequent surgery (94% target) 91.6% 96.4%

Patients waiting less than 31 days for subsequent drug treatment (98% target) 100% 100% 100% (Q1) to 100% (in Q2 to date)

Patients receiving first treatment within 62 77.4%(Q1) to 80.9% (in Q2 to date) days of urgent GP referral (85% target) 86.7% 69.9%

Patients treated 62 days of screening (90% 92.5% 86.2% 91.8%(Q1) to 87.1% (in Q2 to date) target)

Patients treated within 62 days of consultant 87.7% 96.5% upgrades (90% target) 83.8% (Q1) to 96.6% (in Q2 to date)

Please note: Validation is still on-going for December figures. ResponsivenessXXXX 13 CancerXXXXX Board Sponsor XXXXDirector of Operations

Commentary XXXX XXXXXThe final position of cancer XXXXtargets in January showed the Trust had delivered on 3 of the 8 cancer waiting targets; the subsequent drugs and screening targets. The 2WW targets were not met in January as expected predominantly due to patient choice to delay appointments over the Christmas period. The 2WW targets will be met again in February.

Performance on the 62 day pathway in December was validated at 86.2%, passing the target however the Trust is predicted to fail in January and performance is expected to improve in February but not deliver the 85% target. The Trust did not deliver the 31 day target in January and is predicted to below trajectory in February. This is predominantly due to problems in the Urology pathway which is receiving increased focus from the management team and a further remedial action plan has been developed to build on previous work.

ResponsivenessXXXX 14 CancerXXXXX Board Sponsor XXXX Director of Operations

Commentary XXXX TheXXXXX national deadline for validatedXXXX February data is 4th April and the team internally are working towards this. The ‘unvalidated’ February position currently has the Trust passing 5 of the 8 key targets.

The Trust has passed the 31 subsequent drug treatment target every month in the past year and for subsequent surgery the Trust is currently passing this for February based on the ‘unvalidated’ positon. The actual number of patients treated against the screening and consultant upgrade targets is relatively small and can be seen to fluctuate due to a small number of breaches in this pathway. A pass position for both targets for Q4.

The Trust has worked to develop timed pathways for all disease areas that have experienced problems in delivering cancer target. Work is now underway to move from development to consistent delivery of these timed pathways. XXXXResponsiveness 15 XXXXXCancer Board Sponsor Sponsor XXXX Director of Operations Commentary Referral to Treatment 62 Day PTL: Number of patients treated within the specified period including Commentary

tertiary referrals (irrespective of when referral received) - January data XXXX AllXXXXX patients on a cancer pathway areXXXX actively tracked by the cancer Number of patients Number of Days services team using detailed No. of Patient Tracking Lists and Wit Patients Mean Max 32 - 39 - 49 - 63 - 77 - 91 - After potential delays to pathways are hin Treated in Wait Wait 38 48 62 76 90 104 104 31 escalated to directorate teams the Period and clinical colleagues.

Breast 21.0 51 102 4.0 4.5 0.0 6.5 4.0 1.0 1.0 0.0 If a patient breaches a cancer waiting times treatment target the Breast Symptomatic 1.5 46 53 0.0 0.0 0.5 1.0 0.0 0.0 0.0 0.0 pathway for the patient is reviewed to identify the reason Colorectal 5.5 60 82 0.0 0.0 1.0 4.0 0.0 0.5 0.0 0.0 for the breach (which is recorded on the cancer register) and the CUP 0.5 33 33 0.0 0.5 0.0 0.0 0.0 0.0 0.0 0.0 clinical team are asked to comment on any potential risk Gynaecology 4.0 63 106 0.0 0.0 0.0 3.0 0.5 0.0 0.0 0.5 this delay has had on the patient care or potential outcomes. Haematology 2.5 32 42 1.5 0.0 1.0 0.0 0.0 0.0 0.0 0.0 Actions, risks or queries are actioned as appropriate within Lung 6.0 73 180 2.0 1.0 0.5 0.5 0.5 0.0 0.0 1.5 the directorate or the wider Sarcoma 5.0 42 64 2.0 1.0 0.0 1.0 1.0 0.0 0.0 0.0 cancer services team.

Skin 24.0 42 140 12.0 4.0 3.5 1.5 0.0 1.0 1.0 1.0 The table illustrates the timeframe patients on a 62 day Upper GI 7.5 46 77 1.5 3.0 0.0 2.0 0.5 0.5 0.0 0.0 pathway were treated in and further internal analysis of all the Urology 50.0 71 182 5.5 4.5 8.5 9.5 5.5 4.0 5.0 7.5 patients that wait beyond 62 days is conducted post validation. TOTAL - Excluding Breast 126.0 58 182 28.5 18.5 14.5 28.0 12.0 7.0 7.0 10.5 Symptomatic

XXXXResponsiveness 16 XXXXXCancer Board Sponsor Sponsor XXXX Director of Operations

Commentary Decision to Treat to Treatment 31 Day PTL: Number of patients treated within the specified period XXXX including tertiary referrals (irrespective of when referral received) - January data TheXXXXX table illustrates the timeframeXXXX patients on from their Number of Patients Number of Days decision to treat date until the % of No of date of actual treatment. No. of patients patients Patients treated treated 49 Mean Max Withi 32 - 39 - 63 - 77 - Treated in who are who are - Wait Wait n 31 38 48 76 90 the Urgent Urgent 62 Period GP GP referrals referrals

Brain/CNS 10 0 0 1 7 10 0 0 0 0 0

Breast 39 51.28 20 15 42 36 2 1 0 0 0

Colorectal 18 22.22 4 7 30 18 0 0 0 0 0

CUP 1 100 1 0 0 1 0 0 0 0 0

Gynaecology 3 33.33 1 2 7 3 0 0 0 0 0

Haematology 11 27.27 3 5 28 11 0 0 0 0 0

Lung 10 40 4 0 0 10 0 0 0 0 0

Sarcoma 4 100 4 7 12 4 0 0 0 0 0

Skin 44 63.64 28 11 31 44 0 0 0 0 0

Upper GI 10 50 5 0 5 10 0 0 0 0 0

Urology 103 60.19 62 12 65 89 2 6 5 1 0 TOTAL 253 52.17 132 10 65 236 4 7 5 1 0

XXXX 17 XXXXXQUALITY PATIENT SAFETY & EFFECTIVENESS SROBoard Sponsor Chris XXXX Burton Medical Director & Sue Jones Director of Nursing

Section Summary Improvements & Actions Midwifery 1:1 care in labour is now at 95%, this is a significant improvement from a year ago and reflects improvements in Midwifery staffing and ability to manage the workload with much reduced unit closures

Gender breaches have been resolved in Interventional Radiology (gate 19) at night, and those occuring in the ED observation unit during surge are part of an action plan jointly agreed with commissioners and weekly monitoring process.

Trends

Standardised mortality ratios continue to show lower risk of mortality for care in NBT than national benchmarks

Areas of Concern Three wards have again triggered the early warning QUESST Tool, Ward 8a who also triggered last month have intensive support and a ward based Matron. Also triggering this month are the Acute Medical Unit who we have been supporting for a while, their main issue is vacancies, active recruitment is in place and the directorate support staffing daily; and for the first time South Bristol Dialysis unit due to sickness and unusual demand on the service.

Safe staffing is maintained as demonstrated in the fill rates for Registered Nurses and HCAs

XXXXSafety 18 XXXXXSummary Dashboard Board SponsorSponsors XXXX Director of Nursing & Medical Director

Patient Safety Dashboard

Most recent February 2016 quarter’s performance Standard Performance Against NBT Trend from Performance to (quarter 2 Jul - against Trajectory last month be achieved by.. Quarterly Trend (Q1 vs Q2) Sept 15 against (target) national (as per trajectory) target / national target contract

Never Event Occurrence by Managed via month (0 target) 0 n/a Quality 1 event (in Q1) to 1 event (in Q2) Committee

Safety Thermometer – overall compliance (94% internal 93.1% n/a Achieving 93.8% (in Q1) to 94.5% (in Q2) target, 92% external target)

Malnutrition Screening (90%) 78.5% TBC 86.9% (in Q1) to 83.9% (in Q2)

Hand Hygiene Compliance Managed via (95%) 96.5% n/a Infection 95% (in Q1) to 96.9% (in Q2) Control

MRSA (0 per month trajectory) 0 n/a Achieving 0 cases in 2014/15 to 2 cases (in Q2)

C-Difficile (<5 per month) 4 n/a Achieving 21 cases (in Q1) 16 cases (in Q2)

MSSA (<1.5 per month) Managed via 1 n/a Infection 5 cases (in Q1) to 9 cases (in Q2) Control

Venous Thromboembolism Managed via Screening (95%) reported 96.6% n/a Thrombosis 95.1% (in Q1) to 94.4% (in Q2 to date) Committee

Dementia (find/assess/refer CQUIN) (90%) (October) 89.7% n/a Achieving 91.8%(in Q1) to 91.9% (in Q2)

Please note: Subsequent validation by clinical teams can alter scores retrospectively. Data correct at time of publication. XXXXSafe Staffing 19 XXXXXWard Early Warning Trigger Tool (QUESTT) & Acuity & Dependency Board Sponsor XXXX Director of Nursing

Commentary This tool is triangulated and used by the DirectorXXXX of Nursing and Heads of Nursing to XXXXXensure early support is given to wards and XXXXdepartments when required. 88% of wards submitted in February , the 5 areas who did not submit have been reviewed by their heads of nursing to ensure any concerns are reviewed. QUESTT is RAG rated with wards scoring 12 and above recorded as Red Gate 8a- Reasons: vacancies, sickness, appraisals not completed, complaints. Key quality indicators not reviewed Actions: Matron ward based for past month. Vacancies recruited to but awaiting start dates, Practice Development Nurse in post to support all new starters. Key quality Indicator review by Head of Nursing underway. Complaints responded to Acute Medical Unit – Reasons :Vacancies, Unfilled shifts, Sickness , complaints, Unusual demands on service exceeding capacity to deliver. Action: Shortfall of vacant shifts filled with temporary staff when able, support from other wards to manage queue of patients awaiting admission .Vacancies being recruited into, sickness closely managed by Matron. Reviewing complaints to ensure lessons learned. South Bristol Dialysis Unit – Reasons: sickness, no evidence of resolution to recurring themes, Unusual demands on service exceeding capacity to deliver, Ward/department appears untidy ,No evidence of effective multidisciplinary/multi- professional team working. Actions: Unit monitored closely by Head of Nursing and support provided to resolve the environmental and building issues , with the cleaning contract recently transferred to NBT Management. Resolution of IT issues achieved and sickness managed in line with policy. SafeCare All inpatient wards excluding Midwifery record patient Acuity and Dependency twice a day using the SafeCare Module on Health Roster. Compliance with using the tool is improving with ongoing training and use of the tool.

XXXXSafe Staffing 20 XXXXXNursing Workforce Board Sponsor XXXXDirector of Nursing

CommentaryCommentary XXXXNursing spend on the inpatient XXXXXwards has increased this for the XXXXsecond month, due to an increase in agency use. WTE per bed has also remained high with the increased acuity of patients.

The increase in WTE/bed is largely due to the numbers of patients requiring ‘Enhanced care’ on several wards, this has also led to an increase in the ratio of unregistered to registered nurses.

This is being triangulated against the SafeCare electronic acuity and dependency tool which is now being completed twice daily on all wards.

All Directorates have produced a Ratio of Registered : Unregistered Ward Nurses (Target 60:40) temporary staffing trajectory which is reviewed at the Directorate

Performance Reviews with the

aim to reduce agency spend to

14 15

- 15

14 15

15 16

14 15

- -

15 16

- -

- - -

- maximum of 5.7% by Q3 / Q4.

- -

June Nov Dec Jan Feb Mar Apr May July Aug Sept Oct Nov Dec Jan Feb Oct Agency expenditure in February 58: 58: 58: 58: 58: 59: 57: 57: 56: 55: 55: 56: 57: 56: 56: 56: 55: remained high and above the 42 42 42 42 42 41 43 43 44 45 45 44 43 44 44 44 45 planned trajectory for the ceiling of agency spend at 6.6%. Heads of Nursing, Finance, and HR are meeting fortnightly to accelerate progress in reducing agency spend and improving rostering practice.

SafeXXXX Staffing 21 NursingXXXXX Workforce Board Sponsor XXXXDirector of Nursing

Commentary During February there has been a continued requirementXXXX for temporary staff to be XXXXXemployed to staff escalation areas, cover XXXXabove plan for sickness, provide care for increased acuity and to support increased surge in the Emergency Zone. The following units have flagged as having staffing fill rates less that 80%:

NICU Fill rates for Registered staff on Nights was 76.7% , however NICU has seen a reduced number of babies in this period. Therefore planned staffing numbers have been constantly reviewed with decisions made to not fill shortfall shifts which occurred due to sickness or vacancy, if assessed as not being required for the daily dependency of the Unit. This is overseen by the Matron each day to ensure safety.

Riverside The fill rate for Care Assistants on nights was low for the first time at Riverside. Patient safety was maintained throughout and the fill rate of Registered Nurses supported the shortfall as demonstrated at 140%.

Gate 9A Dec. Data 2015 Day shift Night Shift The Registered Nurse fill rate on days was 79.9%, with a Care assistant fill rate of 113%. RN/Midwife Fill rate % CA Fill rate % RN/Midwife Fill rate CA Fill rate The head of nursing has been monitoring this Cossham 100.0% 100.0% 98.0% 100.0% ward closely to ensure that safe staffing is maintained and support has been provided to Riverside Unit 103.3% 118.2% 109.7% 148.4% cover some shortfalls by the Supervisory Southmead 94.5% 118.9% 96.8% 132.5% ward sister.

The % fill rates of Care Assistants on both days and nights has reduced this month but The numbers of hours Registered Nurses (RN) and Care Assistants (CA), planned and actual, on both day still reflects the number of patients on the wards requiring ‘Enhanced Care.‘ The ‘ Scale and night shifts are collated manually by each gate/ department every month. This data is uploaded on up’ of the 90 Day Innovation programme is UNIFY for NHS Choices and also on our Website showing overall trust position and each individual gate underway with 17 wards recently joining the level. Further commentary for these areas and the breakdown for each of the ward areas are available programme. This involves daily assessment and review of all patients receiving ‘ now on the external webpage. Enhanced Care’ by a Matron/ Senior Nurse and aims to improve patient experience quality and cost efficiencies.

XXXXSafe Staffing 22 XXXXXMaternity Board Sponsor XXXX Director of Nursing

DON52 Commentary 999 This report provides information about midwiferyXXXX staffing and will track for the Midwife to Birth Ratio board,XXXXX the occasions when Central XXXXDelivery Suite is unable to take admissions and why.

Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 The Midwife to birth ratio is 1:30 for the month of February, which benchmarks 1:35 1:34 1:32 1:32 1:32 1:32 favourably within the south west.

Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 1:1 care in labour in February is 95.9%, this is an improvement of 7.4% from year 1:32 1:32 1:33 1:30 1:29 1:30 14/15 when it was 88.2%.

A rolling programme of recruitment was introduced in April 2015 Newly appointed staff are now in post and have completed the supernumerary process.

5 day per week Caesarean section lists DON51 DON53 have been piloted since Sept 1st 2015, 999 999 and have been successfully approved to continue in 2016/17 through business planning.

Acuity and number of midwives required is monitored for delivery suite 4 hourly during the 24 hour period (The Birth-rate plus acuity tool).

February 2016 has seen 2 closures due to capacity. There has been an increase in births since February 2015 of 2.5% with February 2016 being 475 births. NBT are seeing greater acuity in women on CDS (raised BMI, medical conditions.) requiring more intensive management.

XXXXQuality & Patient Safety 23 XXXXXAdditional Safety Measures Board Sponsor XXXX Director of Nursing

Serious Incidents 3 Serious incidents were reported to STEIS in February 2016: • 1 x Unexpected Death • 2 x Serious Fall

Summary of SIs: The unexpected death SI relates to an patient with liver impairment presenting at AEC very unwell. They were admitted . A central line was inserted in the medi- rooms. The patient was sent to the ward with a raised lactate where they consequently arrested and died. The falls relate to: 1 x Fractured Neck of Femur 1 x Subdural haematoma.

Serious Incident Rate The general trend for Directorates remains generally unchanged

Incident Reporting Overall, reporting is gradually increasing, per 1000 bed days and has settled at approximately 35 to 40 incidents per 1000 bed days. This graph includes all patient safety related incidents reported by trust staff and refers to issues identified on admission and on transfer from other hospitals.

External Reviews of Incident reporting Three independent sources of external review have covered the Trust’s incident reporting systems; • CCG Thematic review – Dec 2015 • KPMG Internal Audit – Feb 2016 • CQC Inspection – Dec 2015 Now that reports for all 3 have been received and reviewed a single overall response plan is being compiled for review at the Trust’s Quality Committee in March.

XXXXQuality & Patient Safety 24 XXXXXAdditional Safety Measures Board Sponsor XXXX Director of Nursing

Incident reporting deadlines No serious incidents breached the submission deadline in February .

Top SI Types in past 12 months Other categories: Missed Diagnosis 2 In the rolling 12 month period falls Incorrect Test Results 2 continue to be the most prevalent. Retained Foreign Object 2 Pressure ulcer incidents are on a Delayed diagnosis 1 downward trend. Unexpected Lost to Follow Up 1 deaths remain at consistent levels. Wrong Site Surgery 1 Maternal Death 1 Information Governance 1 Other categories: Surgical Complication 1 Missed Diagnosis 2 Wrong Route Medication 1 Incorrect Test Results 2 12 Hour Trolley Breach 1 Retained Foreign Object 2 Unintended Damage to Organ 1 Delayed diagnosis 1 Unexpected Admission to NICU 1 Lost to Follow Up 1 Wrong Site Surgery 1 Maternal Death 1 Information Governance 1 Patient Medical Surgical Complication 1 Facilities Safety Devices Data Reporting basis Wrong Route Medication 1 New Alerts 0 5 1 The data is based on the date a serious incident is 12 Hour Trolley Breach 1 reported to STEIS. Serious incidents are open to being Unintended Damage to Organ 1 Closed Alerts 0 5 0 downgraded if the resulting investigation concludes the Unexpected Admission to NICU 1 Open alerts (within incident did not directly harm the patient i.e. Trolley 2 0 1 target date) breaches. This may mean changes are seen when CAS Alerts compared to data contained within prior months’ reports. Breaches of Alert No safety notices breached the 0 0 0 target target dates.

XXXXSafety 25 XXXXXHarm Free Care Board Sponsor XXXX Director of Nursing

CommentaryHarm Free Care The trusts ‘harm free’ rate dropped to 90.7% inXXXX February, which primarily reflected an XXXXXincrease in VTE harms from 0.9% to 3.3% from January to February. The work being drivenXXXX in response to the VTE remedial Action plan is focusing on extending the range of clinical staff engaged with both VTE risk assessment review but also the completion of RCAs for each case of Hospital Acquired Thrombosis. The detail regarding falls is below and pressure ulcer incidence is on the following page.

Overall Falls There were 212 falls in February 2016, compared to 216 in January 2016. The Falls rate per 1000 bed days was 6.49, just slightly under the national average of 6.63 in a winter month under pressures in regard to Flow. There were two Serious Injury Falls in February. A wide range of actions are in progress in line with the Sign up to Safety plan. A ‘Deep Dive’ review of the Trust’s response to patient falls was undertaken at the Trust’s Quality & Risk management Committee on 21 March and will be covered in the related highlight report to Trust Board.

Gender breaches The Trust reported 34 gender breaches in February in the Emergency Department Observational Unit. These occurred on 3 occasions when the Trust was experiencing a significant surge in the Emergency Department requiring patients to be admitted into beds within the Unit, whilst awaiting beds within the Hospital. The risk of gender breaching has been weighed up against the pressures otherwise concentrated in the Emergency Department. Actions: Weekly monitoring and action plan in place and shared with commissioners and the TDA. All breaches are validated against the Service Agreement for Mixed Sex accommodation and CQC guidance. XXXXSafety 26 XXXXXHarm Free Care Board Sponsor XXXX Director of Nursing

CommentaryPressure Ulcers DON21 DON20 999 Pressure Ulcers Grade 2,3,4 YTD Pressure ulcer incidence for Pressure Ulcers Grade 3 (blue),4 (red) YTD 999 XXXX February has significantly reduced to 4 120 XXXXX 6.8 per 10,000 bed days, reflecting Grade2 Grade3 Grade4 21XXXX grade 2 pressure ulcers for 20 100 patients. 3 80 There are no reported grade 3 pressure ulcer for February yea r to 2 60 date total remains at 5 cases (a significant reduction to this point last year of 11 cases). 40

1 Number of PressureUlcers Numberof Number of PressureUlcers Numberof The Trust is in a good position to 20 achieve the target of a 15% reduction of all grades for 2015/6 0 0 under the Sign up to Safety plan.

VTE Risk Assessment DON55 Patients with Grade 2 or above Pressure Ulcers The Trust has received a 999 Rate per 10,000 Bed Days Performance Notice from commissioners and has agreed a 14 Remedial Action Plan. This is overseen through the CCG Quality 12 group and actions planned to deliver 10 improvement in risk assessment performance are scheduled to 8 achieve this by 31/5/16. The primary issue relates to the timeliness of 6 coding rather than the clinical 4 completion of risk assessments. rate perrate10K beddays 2 The Quality Committee is overseeing delivery of actions agreed, with the 0 Thrombosis Committee and a short life working group progressing the work. XXXXSafety 27 XXXXXAdditional Safety Measures Board Sponsor XXXX Director of Nursing

CommentaryDementia The Quality & Risk Management CommitteeXXXX reviewed the outcomes of the 2ndXXXXX dementia carers survey at its March XXXXmeeting. The main findings were that;

•64% of carers were signposted to relevant information •56% had received relevant information & advice •49% were informed of the Dementia/memory café

A range of actions have been agreed to build upon the strong work within dementia care undertaken to date, which was recognised as ‘outstanding practice’ within the recently received CQC reports. The actions will be overseen by the Patient experience Group.

Catheter Compliance Catheter care is audited using the national ‘saving lives’ audit tool, which measures a number of different components split between those relating to initial insertion and those relating to ongoing care. The red line trends show overall compliance across all components calculated as a simple mean, whilst the columns show the ‘Bundle’ score (where one failure on any of the components means the case is viewed as an entire failure). The single cause of the gap in ongoing care relates to poor documentation of the ongoing need for a catheter and this is now the focus to the improvement work required, which is being supported by the quality and safety improvement team.

XXXXSafety 28 XXXXXAdditional Safety Measures Board Sponsor XXXX Director of Nursing

DON DON CommentaryWHO Checklist 27a Malnutrition Screening within 48 Hours of 27b Malnutrition Screening within 48 Hours of XXXXNo data available Admission (for patients admitted for 24hrs or Admission - by Directorate (last 3 Months) more) XXXXXNutrition 100.0% XXXXMalnutrition screening 100.0% 90.0% February compliance was 78% of 90.0% 80.0% Screening on Lorenzo in which the 80.0% adult nursing assessment (includes 70.0% 70.0% nutrition risk assessment) has to be 60.0% 60.0% completed within 12 hours of the 50.0% 50.0% patient being admitted to the ward. This is a slight increase from the 40.0% 40.0% previous months compliance. 30.0% PatientsScreened 30.0% PatientsScreened The change to Lorenzo has 20.0% 20.0% prompted an enhanced expectation 10.0% 10.0% of ward staff, to undertake the 0.0% 0.0% assessment within 12 hours, rather than 48 hours as was the previous standard. This quality improvement drive requires further education beyond the initial Lorenzo training, this is being targeted at ensuring all Senior Nurses undertake the training and additional ‘in situ’ training provided to Registered nurses . This is also being supported by practice development work, including a more detailed nutrition and hydration review and audit to ensure the focus on malnutrition continues. The 2 Directorates where patient are not being screened in a timely way are receiving support for improvement from their Head of Nursing. An action plan has been generated from the results of the audit and will be managed through the Ward Nutrition group. XXXXSafety 30 XXXXXInfection Control BoardBoard Sponsor Sponsor XXXX Medical Director

Commentary Commentary MD03 999 MRSA Cases - Trust Attributable XXXXMRSA 5 XXXXXThere were no reported cases of XXXX MRSA bacteraemia in February 4 2016. The Trusts year to date total remaining at 3 cases.

3 The Trust has agreed Remedial Action Plan with commissioners 2 relating to the increase of MRSA Bacteraemia. The key action was an

Number of MRSA Cases Cases MRSA of Number MRSA policy audit including 1 screening compliance. This has been completed and will be 0 presented at the March Control of Infection Committee.

C. Difficile 4 Trust responsible cases reported for February. There have been 51 reported cases year to date against at national target of 43 maximum.

The contractual maximum of 43 cases relates to those where there is evidence of lapse in care in the Trust. These have been agreed to be 9 in Qtr. 1 and 10 in Qtr. 2 and 7 in Qtr. 3.

The Target for 2016/17 remains at 43 cases.

XXXXSafety 31 XXXXXInfection Control Board Sponsor XXXX Medical Director

Commentary MSSA XXXX 1 Trust responsible cases for XXXXX February. The Trust has breached its internal trajectory of 18 cases for XXXX 2015/16.

The Trust’s involvement in the IPC National collaborative improvement programme in association with Monitor/TDA, which commences in April 2016, will centre on the insertion and ongoing management of indwelling devices which was a key theme from the recent MSSA review.

Hand Hygiene The Trust Hand Hygiene compliance is meeting the Trust standard.

Norovirus During February one ward and one 4 bedded bay was placed under restricted access due to norovirus. This resulted in 179 bed days lost.

Influenza During February the Trust has seen an increase of admissions due to “flu like illness”. The IPC team have worked collaboratively with the clinical and domestic teams to minimise the risk of cross infection within the hospital. .

XXXXEffectiveness 33 XXXXXMortality Board Sponsor XXXX Medical Director

Commentary DataXXXX to December 2015 includesXXXXX information post implementationXXXX of Lorenzo and so the coding data is less reliable than historically. This is likely to be the cause of the significant variation in reported observed and expected deaths in November. This information will correct as the Lorenzo stabilisation takes effect.

XXXX 34 QUALITYXXXXX PATIENT EXPERIENCE SROBoard Sponsor Sue XXXX Jones Director of Nursing

Section Summary

Improvements & Actions

The FFT inpatient response rate has increased to 19.2% and striving to return to the 30% expected response rate. Gate 34A were the top achievers this month with a response rate of 70% and 100% would recommend, this is an outstanding achievement that other wards will gain inspiration from.

Trends Whilst the number of overdue complaints is not yet fully resolved the percentage over 20 days overdue has dropped from 15% in January to 5% in February and work is ongoing to improve the quality of complaint investigation and response.

Areas of Concern Outpatients FFT response rate was a significant drop in month, and work is ongoing to achieve a more sustainable response rate and feedback loop. XXXXCaring 35 XXXXXFriends & Family Test Trustwide Position Board SponsorSponsor XXXX Director of Nursing

NBT % Patients would recommend National % Patients would recommend NBT % patients would not rec The Net Promoter Score (NPS) whilst no longer ……… National Response Rate NBT Response Rate National % Patients would not recommend Response Rate Target aCommentary national requirement is still measured to ------Net Promoter Score provideXXXX greater granularity of patient experience. February 2016 data InpatientsXXXXX •XXXX 97.02% respondents would recommend (940/4791 responses) an increase from January (96.3%) •0.74%% would not recommend (7/940) a decrease from January (1%) •The Net Promoter Score is 76.8 a decrease from January of 83.3 Response rate overall has increased from 13.8% in January to 19.62% (940/4791 attendances) Required rate=30%. Gates with a response rate below 10% will be asked to provide an exception report. Emergency Department Response rate of 11.95% a slight drop from the January rate of 12.10%,532 responses from 4452 attendances) •96.24% of respondents would recommend NBT, a slight increase on January (512 /532 responses) •1.32% would not recommend (7/532), similar to January. Waiting times continue to be cited as the reason for this. •The Net Promoter Score is 73.96, similar January Outpatients Response rate of 1.63%, a huge drop from 4.06% in January less than half the number of surveys returned (556/34192) compared to (1226/30182 attendances. •92% respondents would recommend, down from 94% in January •4% would not recommend up from 2% in January •The Net Promoter Score has dropped to 68.96 Maternity – Overall •96% of respondents would recommend up from 95% in January (278/291 responses) •2% would not recommend.(5/351 responses) •The Net Promoter Score is 70.3 a slight increase from January •The response rate has dropped slightly to 16.16% from 17.84% in January but is still the only service to meet it’s target of 15% .

XXXXCaring 36 XXXXXFriends & Family Test Maternity Pathways Board SponsorSponsor XXXX Director of Nursing

Commentary Maternity – Ante Natal RR Antenatal RR Delivery % Recommend Antenatal Response rate has increase from 13.26% to % Recommend Delivery % Not Recommend Antenatal % Not Recommend Delivery XXXX 16.16% (80/497 attendances) NPS Antenatal NPS Delivery RR Target XXXXX •97.5% significantly more than 94.92% of respondents in January would recommend, XXXX(78/80) 0% would not •Net promoter score = 73.4 up from 64.4 in January Maternity – Delivery Response rate 14.19% down from 19.41%in January (67/472 attendances) •97.01% respondents would recommend an increase from January of 96.19% (65/67) •1.49% would not recommend (1/67) •Net promoter score = 71.6 similar to January Maternity – Post Natal – Inpatient Response rate of 14.55% significantly down from 20.32%, in January (55/378 attendances) • 83.64% would recommend down from 88.76%, in January (46/55) • 7.27% would not recommend, a significant increase from 1.12% in January and will be investigated would n (4/55) Two comments related to poor experience of facilities and work load of staff. •Net promoter score = 45.5 down from 52.3 in January Maternity – Post Natal – Community Response rate of 19.6% down from 21.59% in January (89/454) •100% would recommend up from 98.18% in January and 95.7% in December (89/89) •0% would not recommend •Net promoter score = 82 similar to January •NBT Top Achiever for December is Gate 34A with a Response Rate of 70.1% up from 38.3% in January with 100% respondents likely to recommend, and NPS of 78.7 •Comment of the Month: from Gate 19 Daycase –’The whole department gave me 100% attention when needed. Very supportive and helpful. Being a former nurse for 29 years myself, it was such a pleasure to see our much valued NHS nurses are still giving 100% of their expertise.’

XXXXCaring 37 XXXXXComplaints & Concerns Board Sponsor XXXX Director of Nursing

CommentaryCommentary XXXX 71 complaints and 60 concerns were receivedXXXXX in February. XXXX The NHS 3 day acknowledgement target was 100% compliant and 1 MSK complaint exceeded the NHS 6 month resolution statutory target. 41 cases remained overdue at the end of February down marginally from 43. The backlog continues to reside principally with Medicine and Surgery, who receive the largest numbers (along with MSK and Neuro). ACT has continued to clear all responses received in time for the twice weekly sign-off sessions with the CEO. These are also now independently proof read to improve letter quality. Of the cases closed in January (which allows for capture of overdue cases) the Concerns and Complaints per Directorate compliance rates for closure of complaints and concerns within agreed timescales improved to 82.14%. The exceptions were: • 6.25% were 1-10 days overdue, • 6.25% were 10–20 days overdue • 5.36% greater than 20 days overdue (this compares to 15.38% at end of January).

Backlogs continue to be addressed and as noted above, the most overdue cases have seen the biggest reduction. Enquiry numbers remained consistent at 919 (924 in Jan). Problems with contacting the hospital by telephone and receiving a reply to messages left continue to feature.

XXXXCaring 38 XXXXXComplaints & Concerns Board Sponsor XXXX Director of Nursing

Commentary XXXX TheXXXXX top 3 categories of complaint forXXXX February continue to reflect the ongoing trend; Clinical care, Communication (including Staff Attitude), and Delays and Cancellations. Underpinning some of these issues are the continuing difficulties in tracking patient medical notes.

All written responses continue to be fed back to the directorates to inform style and good practice in responding to complainants. Some initial work has also been undertaken on working with directorate complaint coordinators to improve information sharing and Parliamentary Health Service Ombudsman (PHSO) Cases N.B. If all avenues for complaint resolution standardising case monitoring in Q2 15/16 Q2 15/16 Q3 15/16 Jan-16 Feb-16 Mar-16 have been exhausted line with best practice identified in New Cases referred to and the complainant is certain directorates. 1 3 5 2 3 still dissatisfied with the PHSO Trust’s response, the The recent NHS Choices web- No. of cases fully upheld 0 0 0 0 0 complaint has the right posts on balance reflect positive to take their complaint to comments and Southmead is rated No. of cases patially the PHSO. Cases can as 3½ stars out of 5 (based 363 0 0 0 1 2 take many months from upheld ‘new’ to ‘decision’ which posted ratings) No. of cases not upheld 0 2 4 0 1 means the volumes 3 new cases were reported for shown represent differing time periods investigation by the PHSO in Fines levied Nil Nil Nil Nil 2 and will not therefore February and 3 investigations were ‘add up’ within any given concluded of which 2 were partially Corrective Actions period. upheld. 10 cases remain under Compliant within N/A 2 2 1 1 consideration by the Ombudsman. timescales Non- complient N/A N/A N/A N/A 1

XXXX 39 WellXXXXX Led SROBoard Sponsor Paul XXXX Jones Director of People & Organisation Health Section Summary

Improvements & Actions

. February was another good month for recruitment with 152 wte new starters against a target of 110. Vacancy levels have reduced by 40.24 wte on last month . The first cohort of 12 nurses recruited in Spain started in January. The second cohort of 11 nurses will start at the end of March . Trust voluntary turnover levels remain largely unchanged since August 2015. . A new Sickness Absence Policy, User Guide and FAQs have been agreed and published. The Policy has been streamlined and roles and responsibilities have been clarified. . There was a reduction in the use of temporary staff in February and bank usage was slightly higher than agency usage. However, demand remains above predicted totals. . There are on-going issues resulting from the implementation of the agency cap. This is due to our Framework agencies not agreeing to meet the Feb and April caps.

Trends . Sickness absence levels remain above trust set target of 3.8%. In January the absence rate was 4.9% (4.5% year to date). . Since September 2015, overall compliance in statutory and mandatory training has not been achieved. Some of this has been down to the priority given to Lorenzo training. Compliance in January 2016 overall seen a slight increase compared to the previous month.

Areas of Concern . Appraisal completion rates against plan are at just over 61% year to date. . There is high demand for temporary staffing – particularly for admin and clerical staff due to the Lorenzo Stabilisation Project. Non-framework agency usage has reduced but is still higher than expected. XXXXWell Led 40 XXXXXSummary Dashboard BoardBoard Sponsor Sponsor XXXX Director of People & Organisation Health

January 2016 Most recent NOT Standard quarter’s average Performance Trend from last Quarterly Trend (Q1 vs Q2) (target) against national month performance UPDATED target / contract (Q3 Sept – Dec 15)

Turnover 9.2% 10.5%(in Q1) to 9.6% (in Q2) (voluntary/perm staff) 9.9%

Trustwide Sickness Absence (target 3.8% - 4.9% 4.6% 4.4% (in Q1) to 4.4% (in Q2) in Arrears Nov 15 figure shown) WTE Bank (usage) 622.58 612.9 677.3 (in Q1) to 665.8 (in Q2)

WTE Agency (usage) 203.85 255.7 274.5 (in Q1) to 306.2 (in Q2)

Mandatory Training Compliance (Target 83.6% 83.6% 88.0% (in Q1) to 87.4% (in Q2) 85%) (one month in arrears) WellXXXX Led 41 TurnoverXXXXX Board Sponsor XXXX Director of People & Organisation Health

Turnover DOHR01 Commentary 999 Included: permanent staff who have resignedXXXX voluntarily & fixed term staff whoXXXXX left before the end of their contract. XXXX Excluded: bank workers, locums, junior doctors, service transfers, expected end of fixed term contracts, retirements, dismissals, redundancies, and internal movements/transfers.

Trust voluntary turnover levels remain largely unchanged since August 2015.

There were 146 leavers (126.27 wte) leavers in February compared to 107 (89.45 wte) in January 2016. There were 145 (131.63 wte) starters in February.

The most common reason for leaving (taken from the termination form) in February include : Turnover from Voluntary Resignations • End of fixed term contract/rotation (48) Period % Turnover Period % Turnover • Work-Life Balance (27) Mar 15 – Feb 16 9.9% Mar 14 – Feb 15 10.6% • Promotion (10) • To take up further education/training Feb 15 – Jan 16 9.9% Feb 14 – Jan 15 10.3% (10) Jan-15 - Dec-15 9.8% Jan 14 – Dec 14 10.0% • Relocation (16) Dec-14 – Nov 15 10.1% Dec-13 – Nov 14 9.6% Nov-14 – Oct 15 10.1% Nov-13 – Oct 14 9.5% Turnover in February was highest in the following staff groups : Oct-14 – Sept -15 10.2% Oct-13 – Sept -14 9.2%

Sept 14 – Aug -15 10.1% Sept 13 – Aug -14 9.2% • Add Clinical Services = 29 (24.81 Aug 14 – July 15 10.4% Aug 13 – July 14 8.9% wte) • Admin & Clerical = 31 (24.66 wte) July 14 – June 15 10.2% July 13 – June 14 8.7% • Medical & Dental = 49 (47.40 wte)

June 14 – May 15 10.7% June 13 – May 14 8.1%

May 14 – Apr 15 10.6% May 13 – Apr 14 8.0%

Apr 14 – Mar 15 10.9% Apr 13 – Mar 14 7.6%

WellXXXX Led 42 RecruitmentXXXXX Board Sponsor XXXX Director of People & Organisation Health

Recruitment FebruaryCommentary was another good month for recruitmentXXXX with 152 wte new starters againstXXXXX a target of 110. Vacancy levels haveXXXX reduced by 40.24 wte on last month, partly as a result of recalibrating the funded establishment.

Registered Nurses

• The first cohort of 12 nurses recruited in Spain started in January. The second cohort of 11 nurses will start at the end of March. • The Nurse Recruitment Open Day held on 15th January resulted in 41 offers being made. Unfortunately 8 subsequently withdrew. A second Open Day was held on 11 March, which resulted in 30 offers being made. • 97 Newly Qualified RN’s were invited to recruitment days on 8th and 9th March (75 offers were made). A further advert has been placed inviting applications from newly Staff Group Vacancy WTE February Vacancy Factor February qualified staff with a closing date of Add Prof Scientific and Technic 16.2 7.7 17 April, interviews anticipated early Additional Clinical Services 22.1 5.3 May Administrative and Clerical 75.4 4.7 • The RN pipeline is currently being Allied Health Professionals 36.1 8.0 reviewed together with NQ numbers to make a decision on whether more Estates and Ancillary 68.3 9.6 overseas recruitment is required. Healthcare Scientists 25.3 6.8 • There is a rolling campaign to recruit Medical and Dental 66.2 6.7 to Anaesthetic Assistants (a hotspot Nursing and Midw ifery Registered 148.9 6.3 area) Unreg. Nursing 58.1 5.6 Note : A vacancy is defined as any funded Trust 516.6 6.3 post that is not filled by a substantive or fixed term member of staff [this excludes substantive members of staff on Maternity Leave, Career Breaks and External Paid Secondments, it also excludes funded external staff not contracted by the Trust WellXXXX Led 43 SicknessXXXXX Absence Board Sponsor XXXX Director of People & Organisation Health

DOHR09 SicknessCommentary Absence 056 XXXX SicknessXXXXX Absence XXXX Sickness absence levels remain above trust set target of 3.8%. In January the absence rate was 4.9% (4.5% year to date).

In January, there were 134 long term sickness cases logged with Ask HR and 17 short term sickness cases. 57 long term cases and 19 short term cases were closed.

A new Sickness Absence Policy, User Guide and FAQs have been agreed and published. The Policy has been streamlined and roles and responsibilities have been clarified. To support the roll out of the Policy, there are training sessions open to managers to understand the policy as well as skills training in managing absence.

In addition, videos are being developed to help managers with setting targets and how to conduct formal sickness meetings.

Facilities has the highest rate by Directorate and have set themselves a stretch target of 6.5% to achieve by 31st March 2016. An action plan has been implemented to support this.

Note : sickness absence trajectory has been calculated using seasonal adjusted averages over the last 3 years aiming for target of 3.8% by March 16.

WellXXXX Led 44 PayXXXXX & Agency Usage Board Sponsor XXXX Director of People & Organisation Health

BankCommentary and Agency

ThereXXXX was a reduction in the use of temporaryXXXXX staff in February and bank usageXXXX was slightly higher than agency usage. However, demand remains above predicted totals.

There are on-going issues resulting from the implementation of the agency cap. This is due to our Framework agencies not agreeing to meet the Feb and April caps.

NBT eXtra are currently working with the Consortium to retender for a new Nursing contract, with the current framework agencies being provided notice. There is also initial scoping underway for retender for A&C, AHP’s and Scientific suppliers. This is all being completed as a collaborative piece of work with other Local NHS Trust’s.

Use of temporary RMNs has reduced but demand is unpredictable. All wards are now embracing Enhanced Care and this has led to a reduction in the use of HCAs for 1:1 ‘specialling’ shifts.

There are a number of on-going actions which include : • Action plans to transfer agency locums to Bank, FTC or Substantive posts to reduce our spend • NBT eXtra continue to grow the bank with external advertising and recruitment campaigns. • The process to enrol people onto the bank is being streamlined

Pay Expenditure There was a slight drop in the overall pay spend in February. Agency expenditure reduced also, however there was an increase in bank pay.

WellXXXX Led 45 MandatoryXXXXX Training Board Sponsor XXXX Director of People & Organisation Health

DOHR13 MandatoryCommentary Training Compliance with menu of mandatory training 194 XXXX 100.0% ComplianceXXXXX in January 2016 overall seen a slight increase compared to 90.0% XXXX the previous month. 80.0% 70.0% Communications have been sent recently regarding the link to 60.0% incremental pay and the need to be 50.0% fully compliant in all areas for role. 40.0% These will continue throughout the Spring as we move into the new

Proportionn of staff Proportionn of 30.0% appraisal period. 20.0% 10.0% HR Partners continue to work with department heads to identify gaps in 0.0% training with staff groups, individuals and addressing persistent non- compliance.

Mandatory Training Compliance Non medical Appraisal Compliance Appraisal Completion – non Jan 16 Jan 2016 medical staff Fire 82.3% Year to date completion rates which covers the period from April to the Health & Safety 88.1% end of December (against plan) = 61% . Infection Control 85.7%

The appraisal paperwork is currently Child Protection 83.8% being updated to take account of the above mentioned changes ready for Manual Handling 78.1% implementation in April 2016.

Information Governance 83.7%

Waste 83.9%

Equality & Diversity 77.7% XXXXWell Led 46 XXXXXMedical Workforce Board Sponsor XXXX Medical Director

Commentary TheXXXX attached appraisal XXXXX XXXXchart shows compliance with the requirement for all doctors to have had an appraisal within 15 months of their last appraisal. The small number of individuals missing this deadline are managed through a robust missed appraisal escalation process.

FINANCEXXXX 47 SROXXXXX Catherine Phillips Director of Finance Board Sponsor XXXX

Section Summary Summary For the year to date the Trust has a deficit if £49.1m which is £23.1m adverse to plan • The primary drivers for the adverse to plan were lower than planned contract income of £12.4m together with pay overspends of £7.4m coupled and a non-pay overspend of £3.1m. The cash balance is £1.5m, which includes £43.1m of the in-year borrowing drawn down from the Department of Health, being £27.8m revenue loan taken out in November and £15.3m remaining revolving working capital facility. • Non PFI capital expenditure totals £18.2m which is £10.5m below the plan for the year to date. • The Trust is rated red by the Trust Development Authority (TDA) as a result of the planned and forecast deficit. Areas of concern • Elective inpatient performance continues to be lower than plan. Contract Income is £12.4m below plan notably in elective activity of £4.8m with the impact of penalties, CQUIN and other activity below plan by £7.6m. • Pay expenditure was £7.4m overspent for the year, primarily reflecting a combination of above plan use of temporary staff in Nursing and Medical agency. Impacted by above plan sickness and patient acuity. • Non Pay expenditure was £3.1m overspent for the year. This reflects overspends on drugs and clinical supplies and services. • Cash payments are being managed to avoid cash going overdrawn.

Actions • Focus on the improvement of elective activity • Reduction in dependency on and use of bank, locums and agency meeting the defined agency caps. • Daily monitoring of cash, with increased efforts devoted to raising income and collecting outstanding debt. XXXXFinance 48 XXXXXStatement of Comprehensive Income Board Sponsor XXXX Director of Finance

In month Commentary Position as at 29 February 2016 variance (Adv)/ AssurancesXXXX Fav XXXXX Variation from The financial position for January Budget £m Actual £m budget (Adv) / £m XXXX Fav £m shows a deficit of £49.1m compared with a planned budget Income deficit of £26m. This represents Contract Income 437.0 424.6 (12.4) (1.8) an adverse position to plan of Other operating income 71.1 70.1 (1.0) 0.0 £23.1m for the year to date. Donations income for capital acquisitions 0.0 1.5 1.5 0.0 Key Issues Total Income 508.1 496.2 (11.9) (1.8) Contract income is £12.4m Expenditure adverse to plan driven by under Pay (321.2) (328.6) (7.4) (0.7) delivery from elective specialties Non-Pay (160.8) (163.9) (3.1) (0.1) in addition to contractual Total Expenditure (482.0) (492.5) (10.5) (0.8) penalties, shortfall on CQUINS and marginal tariff impacts.

Earnings before Interest & depreciation 26.1 3.7 (22.4) (2.6) Pay was £7.4m adverse to plan, 0.75% driven by high agency/bank usage for the year. Depreciation & Amortisation (19.9) (19.6) 0.3 0.0 Non PFI Interest receivable 0.1 0.0 (0.1) 0.0 Actions Planned Non PFI Interest payable (1.3) (1.8) (0.5) 0.0 Continued Implementation of PFI Interest (30.2) (30.2) 0.0 0.0 recovery plan actions to reduce PDC Dividend (0.8) (0.3) 0.5 0.0 agency expenditure and increase Impairment 0.0 0.0 0.0 0.0 Retained Surplus / (Deficit) for accounting elective activity. Additional (26.0) (48.2) (22.2) (2.6) purposes workforce controls introduced.

Add back items excluded for NHS accountability IFRIC 12 Adjustment 0.0 0.0 0.0 0.0

Donations income for capital acquisitions 0.0 (1.5) (1.5) 0.0 Depreciation of donated assets 0.0 0.6 0.6 0.1 Impairment 0.0 0.0 0.0 0.0 Adjusted Surplus / (Deficit) for NHS (26.0) (49.1) (23.1) (2.5) accountability

XXXXFinance 49 XXXXXStatement of Financial Position Board Sponsor XXXX Director of Finance

29 February 29 February Variance above 31 January Commentary 31 March 2015 2016 Plan 2016 Actual / (below) plan 2016 XXXX Actual £m £m £m £m Actual £m AssurancesXXXXX XXXX Non current assets The Department of Health 508.3 Property, Plant and Equipment 517.7 498.8 (18.9) 498.1 approved loan of £27.79m was 0.4 Intangible Assets 0.3 4.2 3.8 4.2 received in November, which was 508.8 Total non-current assets 518.1 503.0 (15.1) 502.3 used to repay part of the working capital support facility. Total Current Assets borrowing in-year, remains at 7.9 Inventories 7.9 8.8 0.9 8.9 £43.1m, which is £7.3m higher 15.8 Trade & other Receivables NHS 15.8 18.3 2.5 16.1 than planned. 25.2 Trade & other non-receivables Non-NHS 18.0 29.8 11.8 24.3 1.0 Cash and Cash equivalents 2.9 1.5 (1.4) 2.1 Concerns & Gaps 50.0 Total Current Assets 44.7 58.4 13.7 51.4 31.7 Non-current assets held for sale 22.5 31.1 8.6 31.1 Better Payment Practice Code 590.5 Total Assets 585.3 592.5 7.2 584.8 (BPPC) is below the required 95% with 77% of payments made Current liabilities (< 1 year) within 30 days. This 7.5 Trade & other payables – NHS 7.5 10.5 3.1 9.6 performance will not improve by 76.9 Trade & other payables – Non-NHS 74.1 89.6 15.5 82.5 the end of the year due to the 1.4 Borrowings 1.4 1.4 0.0 1.4 cash management actions being 10.5 PFI liability (current) 10.5 10.5 0.0 10.5 undertaken. 96.3 Total current liabilities 93.4 112.0 18.6 104.0 (14.5) Net current assets / (liabilities) (48.8) (53.6) (4.8) (52.6) 494.2 Total Assets less current liabilities 491.8 480.5 (11.3) 480.8 7.4 Trade payables and deferred income 7.0 12.2 5.2 7.1 Actions Planned 416.1 PFI liability 407.3 407.3 (0.0) 408.1 Ongoing daily cash monitoring to ensure the Trust is able to stay 19.5 Borrowings 15.6 61.9 46.3 61.9 within the cash limits set under 51.2 Total Net Assets 62.0 (0.9) (62.8) 3.7 the revolving working capital Capital and Reserves facility and loan agreements. 241.3 Public dividend capital 277.1 241.3 (35.8) 241.3

(242.2) Income & Expenditure reserve (269.6) (264.1) 5.5 (264.1)

(27.4) Income & Expenditure account – current year (26.0) (48.2) (22.2) (43.6)

79.5 Revaluation reserve 80.4 70.1 (10.4) 70.1 51.2 Total Capital and Reserves 62.0 (0.9) (62.8) 3.7

XXXXFinance 50 XXXXXFinancial Risk Ratings Board Sponsor XXXX Director of Finance

Commentary XXXX AssurancesXXXXX SufficientXXXX cash for our planned 1. TDA Overall Risk Assessment Criteria Rating: deficit has been made available to the Trust via the interim Year to date Forecast working capital facility and DH loan. Trust Overall Rating Red Red Concerns & Gaps

The Trust has a red rating on the TDA risk assessment criteria as a 2. Financial Sustainability Risk Ratings: result of the deficit for 2015/16.

The TDA also measures the Indicator Weight Year to date Forecast Trust against the risk ratings used by Monitor. Overall rating 1 2

XXXXFinance 51 XXXXXRolling Cash Flow Forecast, In Year Surplus, & Capital Programme Expenditure Board Sponsor XXXX Director of Finance

CommentaryCommentary Rolling cash flow forecast In Year Deficit (before impairment) - plan vs 10 actual XXXX TheXXXXX Trust is currently below plan (10) onXXXX income and expenditure for 0.0 the year to date and forecast to continue to the year end. (30) -5.0 £m -10.0 -15.0 Assurances

(50) £m

- -20.0 -25.0 Planned capital expenditure for (70) -30.0 the year is £30.5m. £23.9m -35.0 before PFI phase 2 (£6.6m).

(90) DeficitYearIn -40.0 Expenditure for the year to date Month -45.0 is £18.2m. Forecast including support -50.0 Forecast excluding support Plan Actual Actions Planned

DOFXX Only necessary capital XXX Capital Programme - cumulative expenditure will be incurred. expenditure trend and projection against Cash will be closely managed in 35 budget the final month of the year. 30 Payment runs to suppliers will be

25 affected to avoid the cash

20 position becoming overdrawn.

£m 15 10

5 0

Plan Actual

XXXXFinance 52 XXXXXSavings Board Sponsor XXXX Director of Finance

Commentary Trust 2015/16 XXXX Annual CRES Position (In Year) XXXXXAssurances XXXX 35 Red Savings review meetings are in 30 place to ensure in year implementation and development Amber 25 of future years plans. 20

£m Green Concerns & Gaps 15 10 The first graph shows in-year Target delivery which totals £27.3m. 5

0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month Actions Planned Focus on savings Programme delivery and identification of schemes for 2016/17 including the Trust 2015/16 Monthly CRES Position impact of Carter at January 2016 recommendations. 4,000 Green 3,500 3,000 2,500 2015/16 Target 2,000

£000 1,500

1,000 Plan 500 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Month

XXXXREGULATORY VIEW 53 XXXXXOverall Commentary Board Sponsor XXXX Chief Executive Officer

Summary

The Governance Risk Rating (GRR) for ED 4 hour performance continues to be a challenge through 2015/16, actions to improve and sustain this standard are set out earlier in this report. A recovery plan is in place for RTT incompletes and long waiters (please see Key Operational Standards section for commentary). Cancer figures are undergoing final validation therefore, whilst indicative, the figures presented are not necessarily reflective of the Trust’s finalised position.

We are scoring ourselves against the TDA Accountability Framework (AF). This requires that we use the performance indicator methodologies & thresholds provided and a Finance Risk Assessment based upon in year financial delivery & Monitor’s Risk Assessment Framework.

Board compliance statements – number 4 (going concern) and number 10 (ongoing plans to comply with targets) warrant continued board consideration in light of the in year financial position (as detail within the Finance commentary) and ongoing performance challenges as outlined within this IPR. The Trust is committed to tackling these challenges and revised recovery trajectories have been submitted to the TDA as outlined elsewhere in this report and are scrutinised on an ongoing basis through the monthly Integrated Delivery Meetings.

CQC reports history (all sites)

Regulatory Area Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Location Standards Report 15 15 15 15 15 15 15 15 15 16 16 Met date Overall Requires Feb-15 Improvement Finance Risk Rating Red Red Red Red Red Red Red Red Red Red Red Child and adolescent Good Feb-15 (FRR) mental health wards (Riverside)

Specialist community Requires Feb-15 Board non-compliance 1 1 1 1 1 1 1 1 1 1 1 mental Improvement statements health services for children and young people

Prov. Licence non- 0 0 0 0 0 0 0 0 0 0 0 Community health services Outstanding Feb-15 compliance for children, young people statements and families Southmead Hospital Requires Feb-15 CQC Inspections RI RI RI RI RI RI RI RI RI RI RI Improvement

Cossham Hospital Good Feb-15

Frenchay Hospital Requires Feb-15 Improvement XXXXRegulatory View 54 XXXXXMonitor Provider Licence Compliance Statements at February 2016 Board Sponsor XXXX Chief Executive Officer Self -assessed, for submission to NTDA Ref Criteria Comp Comments where non compliant or at risk of non-compliance Ref Criteria Comp Comments where non compliant or at risk of non-compliance (Y/N) (Y/N) Fit and proper persons as Existing processes sufficient. All Executive and Non-Executive Directors have completed a self assessment Fit and proper persons as Yes Existing processes sufficient. New requirements have been discussed and processes are being put in place Governors and Directors (also Yes and no issues have been identified. A Fit and Proper Person Policy is being developed for approval in G4 Governors and Directors (also to ensure complianceSeptember with 2015.the new regulations. G4 applicable to those performing applicable to those performing equivalent or similar functions) equivalent or similar functions) Having regard to monitor The Trust Board has regard to Monitor guidance where this is applicable Registration with the Care Yes CQC registration is in place. No outstanding non-compliance actions with CQC. The Trust is scheduled for G5 Guidance Yes G7 Quality Commission inspection by the CQC in early November 2014. Registration with the Care CQC registration is in place. The Trust received a rating of Requires Improvement from its inspection in Patient eligibility and Yes Trust Board has considered the assurances in place and considers them sufficient. G8G7 Quality Commission November 2014. A number of compliance actions were identified which are being addressed through an selection criteria action Plan. The Trust Board receives regular updates on the progress of the action plan through the IPR. P atient eligibility and Yes A range Trustof measures Board has and considered controls are the in assurancesplace to provide in place internal and assuranceconsiders themon data sufficient. quality. Further Yes developments to pull this together into an overall assurance framework are planned through strengthened G8P1 sRecorelectidoning cr ofiteria info rmation Information Governance Assurance Group. A range of measures and controls are in place to provide internal assurance on data quality. Further Yes Information provision to Monitor not yet required as an aspirant FT. However in preparation for this the Trust P1P2 PRecorrovisdioning o off i ninfoformrmatationion developments to pull this undertakestogether into to an comply overall with assurance future Monitor framework requirements. are planned through strengthened Information Governance Assurance Group. Assurance report on Assurance reports not as yet required by Monitor since NBT is not yet a Foundation Trust. However, once Yes Information provision to Monitor not yet required as an aspirant FT. However in preparation for this the Trust P2P3 Psurobvmisissionio onfs i ntofo Mrmonatitorion applicable this will be ensured.undertakes Scrutiny to comply & oversight with futureof assurance Monitor reports requirements. will be provided by Trust's Audit Committee as currently for reports of this nature. Assurance reports not as yet required by Monitor since NBT is not yet a Foundation Trust. However, once Assurance report on Yes NBT complies with national tariff prices. Scrutiny by CCGs, LAT and NTDA provides external assurance P4P3 Cosubmmpilssianceions wtoit hM tohnei torNa tional Tariff applicable this will be ensured. Scrutinythat tariff & oversight is being of applied assurance correctly. reports will be provided by Trust's Audit Committee as currently for reports of this nature. Construc tive engagement Yes NBT compliesTrust with Board national has considered tariff prices. the Scrutiny assurances by CCGs, in place LAT and and considers NTDA provides them sufficient. external assurance Yes that tariff is being applied correctly. P5P4 cCoonmcernpliainceng local with tartheif fN ational Tariff modifications Constructive engagement Trust Board has considered the assurances in place and considers them sufficient. The right of patients to make Yes Trust Board has considered the assurances in place and considers them sufficient. P5 concerning local tariff Yes C1 choices modifications T he right of patients to make Yes Trust Board has considered the assurances in place and considers them sufficient. C2 Competition oversight Yes C1 choices Yes Range of engagementTrust Board internally has considered and externally. the assurances No indication in place of any and actions considers being them taken sufficient. detrimental to care Yes integration for the delivery of Licence objectives. IC1C2 CProomvipsieontiti oofn iontveergrsaigtedht care

Yes Range of engagement internally and externally. No indication of any actions being taken detrimental to care IC1 Provision of integrated care integration for the delivery of Licence objectives. RegulatoryXXXX View 55 BoardXXXXX Compliance Statements at February 2016 Board Sponsor XXXX Chief Executive Officer

Self-assessed, for submission to NTDA

No. Criteria Comp No. Criteria Comp (Y/N) (Y/N) The Board is satisfied that, to the best of its knowledge and using its The necessary planning, performance management and corporate and own processes and having had regard to the TDA’s oversight model clinical risk management processes and mitigation plans are in place to (supported by Care Quality Commission information, its own deliver the annual operating plan, including that all audit committee information on serious incidents, patterns of complaints, and recommendations accepted by the board are implemented satisfactorily. 1 Yes 8 Yes including any further metrics it chooses to adopt), the trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients. An Annual Governance Statement is in place, and the trust is compliant The board is satisfied that plans in place are sufficient to ensure on with the risk management and assurance framework requirements that going compliance with the Care Quality Commission’s registration 2 Yes 9 support the Statement pursuant to the most up to date guidance from HM Yes requirements. Treasury (www.hm-treasury.gov.uk). The board is satisfied that plans in place are sufficient to ensure ongoing The board is satisfied that processes and procedures are in place to compliance with all existing targets (after the application of thresholds) as 3 ensure all medical practitioners providing care on behalf of the trust 10 Yes set out in the relevant GRR; and a commitment to comply with all known No have met the relevant registration and revalidation requirements. targets going forwards. The board is satisfied that the trust shall at all times remain a going The trust has achieved a minimum of Level 2 performance against the 4 concern, as defined by the most up to date accounting standards in Yes 11 requirements of the Information Governance Toolkit. Yes force from time to time. The board will ensure that the trust will at all times operate effectively. The board will ensure that the trust remains at all times compliant This includes maintaining its register of interests, ensuring that there are with regard to the NHS Constitution. 5 Yes 12 no material conflicts of interest in the board of directors; and that all board Yes

positions are filled, or plans are in place to fill any vacancies. The board is satisfied that all executive and non-executive directors have All current key risks have been identified (raised either internally or the appropriate qualifications, experience and skills to discharge their by external audit and assessment bodies) and addressed – or there 6 Yes 13 functions effectively, including setting strategy, monitoring and managing Yes are appropriate action plans in place to address the issues – in a performance and risks, and ensuring management capacity and timely manner capability. The board is satisfied that: the management team has the capacity, The board has considered all likely future risks and has reviewed capability and experience necessary to deliver the annual operating plan; 7 appropriate evidence regarding the level of severity, likelihood of it Yes 14 and the management structure in place is adequate to deliver the annual Yes occurring and the plans for mitigation of these risks. operating plan.

Comment where non- As the Trust has not yet achieved a sustainable position in relation to delivery of the 4 Timescale for To be determined and agreed by the Board compliant or at risk of Hour A&E and RTT due to a reliance on external system changes/factors, the Trust is compliance: non-compliance unable to confirm compliance with this statement XXXXIPR / Board Additional Reporting Schedule 2016 56 XXXXXBoard Sponsor All Executive Directors Board Sponsor XXXX

Measures & Reports overseen by Trust Board which fall outside monthly IPR reporting

January February March • Other qualitative aspects of patient experience report • IPR Measure: Research & Innovation • Medical Notes – added to IPR cycle • External Reporting – Coroners Report • Periodic IPR Measure: Clinical Audits • Length of Stay – page to be developed • Flu Vaccination Rates – added to IPR cycle • Facilities cleaning schedule • Delayed Transfers – page to be developed • Cancelled Operations – reasons for cancellations – added • Sterile Services to IPR cycle • Pay bill chart – to be revised • Non Medical Appraisals – last month for reporting for year • Tariff – NBT V Dr Foster removed whilst data queries raised with Dr Foster • Compliments – moved from monthly to quarterly cycle

April May June • Other qualitative aspects of patient experience report • IPR Measure: Research & Innovation • Clinical Legal claims/inquests (6 monthly) • Clinical Audit • Complaints – monthly trends • Clinical Audit • Additional Patient Flow KPIs • Carers Report – quarterly • Acuity & Dependency • Theatre Productivity KPIs • Expanded Medicines Management section • Outpatients KPIs • Staff Survey Results • Vacancy Reporting • CQC action plan & progress

July August September • Other qualitative aspects of patient experience report • IPR Measure: Research & Innovation (page 43) • Staff Survey Results • Carers Report – quarterly (page 46) • CQUINs • IPR Measure: Non Medical Appraisals (page 60)

October November December • Staff Survey Results • IPR Measure: Research & Innovation (page 44) • CQUINs • Carers Report – quarterly (page 39) • Clinical Legal claims/inquests (6 monthly)

56 Annual Equality Report 2014/5

Exceptional healthcare, personally delivered Table of contents

Introduction 2

1 The NBT approach to E&D 4

2 North Bristol NHS Trust Vision and Values 5

3 Section Review Equality Work 2009 - 2013 6

4 Section Leadership 8

5 Patients 9

6 Section Service Delivery Patients 10

7 Case Studies 11

8 Facilities Management 15

9 How did we do? The statistics 20

10 Overall Assessment 21

11 2014 Overview – Staff 22

12 Section Staff Services 26

13 Headline Data 2014 30

14 2015 – future challenges 35

15 Conclusions and recommendations 35

16 Appendix A Abbreviations 37 Introduction North Bristol NHS Trust (NBT) is a centre of excellence for health care in the South West region in a number of fields as well as one of the largest hospital trusts in the UK. The rustT provides a range of acute and community services and employs around 10,000 staff. Around one fifth of our workforce is based outside the traditional hospital setting in the local community. We treated around 114,000 inpatients, including day patients, as well as caring for over 101,000 people in our Emergency Department at Frenchay and our Minor Injuries Units at Southmead and Yate. More than 6,100 babies are born at Southmead, Cossham, at home or elsewhere in the community and we carry out approximately 338,000 outpatient appointments.

Why Equality and Diversity matters to us

North Bristol NHS Trust has drawn up a set of values which is committed to putting patients first, working well together, striving for excellence and recognising the person. This is underpinned by the equality values to ensure that patients, staff and carers are treated with respect, whatever their equality profile and an environment of leadership for equality is encouraged throughout the organisation. The Board provides corporate leadership which is taken up by senior managers throughout the Trust and Corporate Equality Champions were appointed at Board level who give strong leadership to this work. It is important to note that work has been carried out to promote equality and to ensure that discrimination does not happen over a number of years as this fits with our values to treat everyone with respect and dignity. North Bristol NHS Trust (NBT) continues to work towards meeting the legal requirements set out under the Public Sector Equality Duties of the Equality Act 2010 and the objectives of the Equality Delivery System (EDS). Every year we build on our previous success and become more robust in our approach to the equality agenda. We believe that the experience of patients and staff has improved as a result of the equality initiatives we have taken so far and that we have mechanisms in place to support the workforce. NBT is keen to work towards eliminating discrimination, promote equality and advance positive relationships between people with protected characteristics and those without them.

What make 2014 special

2014 was a landmark year for the Trust as in May services were transferred from Frenchay and Southmead hospitals into the new Brunel building. This is at the heart of the Southmead Hospital Bristol site and is supported by existing clinical services including maternity, pathology and breast care which is based in the refurbished Beaufort House alongside a Macmillan Wellbeing Centre. The new hospital dramatically improves privacy and dignity for patients with 75 percent of beds in single rooms with their own en-suite facilities and a clinical corridor which means they do not have to be taken past members of the public before or after their operations. Further, it encourages team working and a greater link between departments. Considering the move to the new hospital in 2014 staff have worked extremely hard in every department to maintain high service standards and to meet the requirements of everyone, whatever their protected characteristic. This report is compiled annually from information provided by departments across the Trust which shows some of the innovative activities that demonstrate how the Trust is meeting its legal obligations. This report also shows the work from 1st January 2014 – 31st March 2015 and gives a review of for previous years.

2 Annual Equality Report 2014/5 All of the protected characteristics are taken into consideration, some departments like Human Resources cover them all and include them in all policies; others work on specific equality areas according to their service. It should be noted that everyone will belong to at least five of the protected characteristics and many areas have embedded these into all they do.

Lesley Mansell Equality and Diversity Manager Human Resources & Development April 2015

Annual Equality Report 2014/5 3 1 The NBT Approach to Equality and Diversity National requirements and changes

Equality Act 2010 - The Equality Act 2010 requires the Trust to publish information to show how we meet the law in that we show “due regard” for equality, that we promote it and do not discriminate. “Due Regard” means consciously thinking about the three aims of the general duty as part of the process to decision making.

Equality Delivery System (EDS) - NBT continues to use the EDS to meet the requirements of the Equality Act 2010 and be better placed to meet the registration requirements of the Care Quality Commission (CQC) and other external auditing bodies. NHS England declared this to be mandatory as of April 2015. The Equality Delivery System 2 has four broad objectives for 2012-2016, although each of these objectives are defined further the overall aims are: Better health outcomes (for patients) Improved patient access and experience A representative and supported workforce Inclusive leadership

Workforce Race Equality Standard - The development of a Workforce Race Equality Standard (WRES) was proposed by NHS England and the Equality & Diversity Council (EDC) in July 2014. Its aim is to improve workplace experiences and employment opportunities for Black and Minority Ethnic (BME) people in the NHS, or those who want to work in the NHS, by taking positive action to help address workforce race inequalities. From 1st April 2015 the Trust will be required to provide baseline statistics and evidence on how it meets the standard. Early indications are that the organisation is in a good position on many of these statistics and can evidence the work it does to support BME staff.

Snowy White Peaks Report - This research by Roger Kline (Middlesex University: 2014) considers the extent of the gap between the diversity apparent in the workforce and the local population in London, and that visible among Trust leaderships and senior management. That gap is then considered in the light of growing evidence about the impact of staff and Board diversity on the effectiveness of healthcare provision and the patient experience. The researchers were especially concerned with tracking ethnicity, but also considered the under-representation of women. The findings showed the proportion of senior and very senior managers who are BME has not increased since 2008, when comparable grading data was available, and has fallen slightly in the last three years. The likelihood of White staff in London being senior or very senior managers is three times higher than it is for Black and Minority Ethnic staff, that the issues explored within London were reflected nationally in every respect. The data demonstrates that there remains a very significant gap between the composition of Trust Boards and national NHS bodies, and the rest of the workforce. Statistics for NBT show a higher percentage of BME board members than for London however the BME staff are largely concentrated in band 5 and work is being done to address this.

The Care Quality Commission (CQC) - The CQC are the independent regulator of health and adult social care in England. One of its principles aims is to promote equality, diversity and human rights to ensure good quality care. To put this principle into practice, the CQC have developed a human rights based approach to regulation. This approach looks at a set of human rights principles – fairness, respect, equality, dignity, autonomy, right to life and rights for staff – in relation to the five key CQC questions focusing on quality of the services.

4 Annual Equality Report 2014/5 2 North Bristol NHS Trust Vision and Values At NBT our vision is: “Exceptional Healthcare, Personally Delivered” which ensures that everyone who uses our services, their carers and staff have the best possible experience. We have developed our values in conjunction with staff and these are: Putting patients first Working well together Striving for excellence Recognising the person Our approach to achieving this is called “iCare” and contains commitments which we place at the centre of everything we do with the aim of guaranteeing the best experience for all. iCare means: I am responsible for Communication that’s effective Attitude that’s positive Respect for patients, carers and colleagues, Environment conducive to care and recovery

Linking National Drivers with our vision and values For North Bristol Trust it has never been the case of just meeting the law, work on equalities is threaded into much of what we do and our aim is putting patients first, ensuring they receive exceptional healthcare that is personally delivered. NBT has drawn up the iCare values in partnership with staff which reflect the requirements set out in the NHS constitution. Previously the Trust implemented equality schemes followed by the Equality Delivery System which gives us a framework and sets our equality objectives. The Trust seeks to develop a safe and supportive environment by demonstrating a commitment to equality throughout the organisation. The information in this report provides patients, staff, the public, Zahir Babur secured a post commissioners, national bodies such as the Care Quality Commission with support from the BME Development Group with headline statistics about how we deliver our employment function, details of service delivery together with the experience of patients and staff and the impact this has over a number of years. We aim to show both quantitative and qualitative information. The Equality and Diversity committee has responsibility to oversee and monitor the work that is carried out, while the equality data gathered helps us to identify how we perform and how we can improve in relation to our objectives which underpin the Public Sector Equality Duty (PSED).

Annual Equality Report 2014/5 5 3 Section Review Equality Work 2009 - 2013

North Bristol NHS Trust Equality Actions

2009 2010 2011 2012 2013

Race, Disability/ EDS introduced. Corporate Exec member Equality Gender schemes Grade Equality takes up Scheme report, merged. LGBT, “Achieving.” Champions Disability consulted on R&B, Age Equality identified for Champion role and published added. Action objectives set Race, LGBT and (mental health) Plan done for next 4 years Gender

Senior manager Recruitment Annual Statistics Consultation takes up BME career dev Process Report BPAC/BME Disability group set up. reviewed compiled/ groups new Champion Offered senior published hospital role (physical level mentors disability)

‘Seldom Heard’ Charter 10 research/ report EQ monitoring standards for with “Hard job applicants, LGBT Charter Trans people to Reach” Mindful race, disability, of 10 Standards approved. patient groups Employer gender, sexual approved by Guidelines to produced, charter – Re- orientation, Board/published support staff impact on awarded. religion/belief & on intranet who transition action plans age produced for for NHS and key staff councils

Dedicated Gypsy/Roma/ Two Ticks New H&B policy Review PWLD liaison Officer Traveller various scheme and Helpline Shaped action for positive health reviewed and re- established planning process Gypsy Travelling initiatives awarded Communities

EQ events marked Lord Mayor of H&B service BME, LGBT HM, Bristol, Leader Consultation feedback IWD, WAD, Disability history of Bristol on access for shows positive IDDP, Chinese month marked Council Labour patients experiences, but New Year. group at LGBT low usage Ramadan fact HM & IWD sheet produced.

6 Annual Equality Report 2014/5 Bristol Pride Charter of 10 “Top 10 survey shows Standards for Staff Equality tips” leaflet 13% staff NBT supportive Disabled staff group re- to welcome undertook environment approved by established Trans people equality training and services to Board/published distributed LGBT people on intranet

NBT signed Project with Equality Training Two Ticks Appt 4 honorary to Mindful bereaved for Employment scheme chaplains: Hindu Employer children in two Services on promoted & Muslim Charter schools disability issues

Gynae – Child Care Electronic SHA – Equality thanked by Services – Staff Record web audit Arts programme female to male Training on refreshed to completed. for staff Trans patient Disability increase equality NBT legally for the excellent and Cultural information complaint care received awareness.

Translating Porters trained Food survey & Access to Work service - 500 on how to Equality Impact engagement promoted on calls received. respond to Assessment with EQ groups Message of the Out of hours deceased process agreed ensure multi- Day BSL service patients of cultural diet met rolled out multi-faiths

Easy Read Mystery Shopper leaflets Patient Equality training Appt Somali link to ensure good produced Experience delivered to workers to meet treatment for in different Group Trust board and needs of local disabled job formats, e.g. established key managers community applicants Braille, large print

Annual Equality Report 2014/5 7 4 Section Leadership The Trust Board has overall responsibility for the equality agenda. They receive the Annual Equality Report and Annual Equality Statistics report. The Board has undertaken equality training and is due to have more on the Workforce Race Equality Standard in 2015. Board and senior managers have become mentors for BME staff.

The Equality and Diversity Manager works in partnership across the Trust with Directorates, with staff and equality groups, Staff Side, Patient Experience Group and externally with other NHS Trusts, the CCG and South West Clinical Support Group, local authorities, mainly Bristol City Council and South Gloucestershire Council HeathWatch, LGBT Forum, Men’s and Boy’s Health Forum, Gypsy, Roma, Traveller Group and Patient Representatives building positive relationships throughout, where the good practice and expertise are often called upon and gained the Trust a reputation as a leader in the equlaity field.

Corporate Equality Champions - There are two Board members, one non-executive and one executive member who lead on equality, they both sit on the Equality and Diversity Committee, which the Executive member chairs.

Further, Trust Board members and senior managers have become corporate equality champions for Race, Disability, Gender and Lesbian, Gay, Bisexual and Trans (LGBT) staff.

Executive Director Walkabouts - The Executive Team take time to go “out and about” in our hospitals and community services visiting staff, talking to their patients and service users. Some are planned visits and others are unannounced. In October 2014 members of the executive were based in different areas of the Brunel Building and staff were invited to meet them and discuss the things of importance, hear updates of what was taking place across the Trust or to identify what support the Executive Team can provide.

Equality and Diversity Committee - This committee has responsibility to ensure that North Bristol Trust is compliant with equality legislation, that services are appropriate, accessible and responsive, that staff have the best skills, that the Trust meets the requirements of relevant audits, promotes good practice, identifies barriers to progress and demonstrates that it respects and values the diversity of our workforce, patients, service users, carers and visitors. It reports to the Workforce Committee which then reports to the Board. It also agrees the Equality Action strategy. Equality is included in the Trust risk register and the E&D committee considers appropriate action to deal with these. It met 5 times from January 2014 – March 2015 and considered:

Redrafted Equality and Diversity Policy

Reviewed its Terms of Reference

Annual Equality Report

Annual Equality Statistics Report

Update reports on the work of the BME and Disabled Staff Development Groups

Equality Objectives and priorities for 2015 – 2016

Respect and Dignity statement for the Trust

Recommended basic IT training for older staff

Staff Attitude Survey Results for 2013

8 Annual Equality Report 2014/5 Annual Harassment and Bullying report

NHS Employers audit of NBT

Family and Friends Test report for patients for 2013-2014

“Snowy Peaks” Research

Equality Impact Assessments

Patient Experience Strategy

NHS England – Equality Delivery System and Race Equality Standard to be mandatory

Equality Award for directorates to achieve

Lead programme - Leadership Development Programme (LEAD) incorporates NBT values including ‘Recognising the Person’ and aims to capacity build skills for future managers. Members were offered “Valued Manager” training on equality and diversity with an external consultant. These are very popular and more are planned in 2015. Other extensive training is also provided e.g. Recruitment, Harassment and Bullying.

There has been widespread training for staff on the iCARE programme which looks at NBT from the patient’s point of view and encourages connections between people that make a difference to service delivery.

5 Patients Aims and objectives - Our aims and objectives are in line with the Trust values and the Equality Delivery System: Better health outcomes for patients and improved patient access and experience which takes into account all the protected characteristics. To support this there is extensive training offered to key managers, targeted training is conducted where requested along with advice provide by the Equality and Diversity Manager. All staff must undertake equality training on the Managed Learning Environment. The Volunteers at an Equality Training Workshop intranet equality pages contain a wealth of information, contact details and is updated regularly. Equality issues are promoted continually, the Equality Newsletter is published monthly and widely available, raising awareness of what is involved. The following shows some of the activities to achieve these overall objectives.

Annual Equality Report 2014/5 9 6 Section Service Delivery Patients Better health outcomes - Access for all patients was increased dramatically when the new hospital building, (Brunel building) was opened in May 2014. Privacy and dignity for patients was increased as 75 percent of beds are now in single rooms with en-suite facilities. There is a clinical corridor which means patients are not transported past members of the public before or after their operations. Further, it encourages team working and a greater link between departments which increases the safety of patients.

There are a number of initiatives that involve service users, like the Patient Experience Group who advise on service delivery and design who have different protected characteristics. CCHP involve young people in service design and interviews for certain posts. Capital Projects engaged with the Bristol Physical Access Chain (BPAC) and BME groups who were asked to review the internal design of the Brunel building.

Engagement was carried out in the early design stage of the Brunel building with the Bristol Physical Access Chain (BPAC) and BME groups who were asked to review the internal design of the Brunel building.

There is a Patient Safety & Clinical Risk Team which reviews clinical incidents and assists with measures to mitigate risk across the Trust and circulates monthly reports to Directorates. The work of the team is integrated across the Trust as their representatives sit on various committees and groups to tackle patient safety and clinical risk issues.

The Central Alert System is managed by the team with alerts being circulated to the relevant areas for action and feedback by the timescales requested.

There are two dedicated staff who deal with Gypsy, Roma and Parvee (GRP) travelling communities. Security have a liaison officer, the post was established when two members of the community were admitted to the Emergency Department. He organised parking for the whole community so they could visit. There is also a dedicated Health Visitor who works closely with members of this community and provides training for other professionals to raise awareness about their requirements in health, education, social care and elsewhere. She arranged vaccinations for GRP children. School nurses also provide immunisation and promote health awareness to young people in secondary schools.

School nurses work in line with the National Child Management programme with checks for height, weight vison and hearing, provide immunisation for year 8 (girls) and year 9 (girls and boys) and give support in secondary schools which includes health promotion, advice on sexual health, sexual orientation and gender.

Improved patient access and experience - Religious, spiritual and pastoral care is offered to patients, visitors and staff of all faiths or none and is a valued part of patient care within Southmead hospital.

It is the policy of the Trust to provide all patients, whose preferred method of communication is not English, with appropriate access to information about Trust services, their treatment and care. In 2014 NBT organised British Sign Language interpreting and foreign language interpretation when requested.

The Fresh Arts Programme organises a number of initiatives throughout the year to improve the experience of patients, their families and carers.

10 Annual Equality Report 2014/5 The Volunteer Service, comprises people drawn from diverse background. They acted as “Move Makers” who are available near the check-in points and reception to offer assistance to any patient. This service proved highly effective immediately after the move into the new building and has continued since.

The Patient Experience Group (PEG) works with the community ensuring that the Trust puts patients at the heart of everything it does. Patient Experience Leads are nominated by every ward. A new Patient Experience Strategy (2014–2017) was drawn up in consultation with staff, patients and carers.

A Complaints and Concerns Policy and Procedure was put in place in 2010 which aims to create a culture that encourages and welcomes patient and service user feedback and gives a commitment to avoid any discrimination against complainants. This is managed by the Advice and Complaints Team (ACT).

Patient Experience Feedback - The National Inpatient survey reported relatively positive experiences. The Family and Friends Test for Patients (2013-2014) show that 94% of patients would recommend our inpatient and maternity services to their family and friends. Equality monitoring is carried out on this test and responses came from a variety of patients with protected characteristics. This showed that Deaf patients had a very positive experience.

7 Case Studies Bristol Centre for Reproductive Medicine (BCRM) - To improve patient access and experience the Centre approached the Equality and Diversity manager for advice on how to engage with the lesbian community. They undertook a programme of outreach work to inform lesbian and single woman of the service as numbers were low. The centre organised an open evening for prospective lesbian and other patients together with existing BCRM service users. This had widespread advertising on screens in the Brunel building, the Trust facebook site and twitter. This reached staff through the NBT bulletin, message of the day, Directorate and Equality newsletters. Dates for open evenings were included in the GPs’ newsletter. A stand was provided at an alternative parenting event and there is an increase in the promotion of alternative families on their website as photos are not all of heterosexual couples.

The first lesbian open evening was very successful. These events are staffed by a multi-disciplinary team, including doctors, embryologists, nurses and admin staff. The members of staff who attend these evenings and provide information to patients include some who are BME, Lesbian and Gay.

Referrals from April 2014 to April 2015 were: Same Sex Couples = 37 Single Women = 40

Patients need to manage their own care and maintain a strict drug regime case studies show that this was not as effective as desired so Patient Information Meetings (PIM) were established where the drug regime is discussed and finally patients receive a 1:1 personally planning appointment which covers injections and drugs and information is provided in a different way.

This is a more consistent method to give information and the centre receives great feedback from patients.

In May 2014 the Treatment Support Service was piloted and was seen as being very successful and has continued ever since. All patients are given a questionnaire to assess their emotional resilience; they are offered this service and patients are continually monitored. If there is evidence of low resilience an appointment is offered with a counsellor for treatment support. The support offered includes counselling, mindfulness group evenings etc. A study has shown if patients are supported emotionally through treatment they will be more likely to return to treatment.

Annual Equality Report 2014/5 11 The BCRM senior management team demonstrates its commitment to promoting good equality practice by:

Setting up a Patient Group which includes heterosexual couples, lesbian couples and single women Service promoted on community radio. A consultant was interviewed on ‘Shout out” a programme for LGBT people. The Equality and Diversity Manager promoted it on Ujima (BME radio station) Monitoring and assessing referrals of lesbian couples and single women on a monthly basis Monitoring all patients who attend the open evenings Having a Lead Nurse for the service for single women Reviewing all paperwork to ensure it is non-discriminatory Producing “fit for purpose forms” to provide an equitable service for all Compiling a leaflet on legal parenting issues where donor sperm is used The main beneficiaries are lesbian couples, single women and male patients who cannot produce semen Questionnaires are monitored recorded and assessed and each section has a KPI Results are presented at monthly quality meetings at BCRM and at directorate Women and Children’s clinical governance meetings These are also reviewed by external bodies that inspect the centre this includes the HFEA regulatory body for Fertility units and ISO (BCRM certified for its Quality Management System (9001:2008)). Donor Sperm – provide BME sperm if at all possible A company who provided donor sperm placed restrictions on the patient groups who were allowed to use the gametes. The result was that an alternative provider was sourced New equipment was bought for disabled patients who require clinical intervention to provide semen The centre provided treatment for a young patient undergoing gender reassignment. The feedback from the patient and their family was very complementary The centre provides a service for people who wish to preserve their fertility before gender reassignment procedures (these may render them infertile) The centre provides equitable services for Lesbian women, single women and patients with disabilities A team member sits on the NBT Equality and Diversity Committee

Patient feedback is extremely positive and includes the comments: “Friendly staff, all rooting for us to succeed. Same sex partner treated equally”. (Dec 2014)

“One couple I spoke to said they’d come up from North Devon because our website made it clear that we welcomed lesbian couples whilst other clinics hadn’t.”

The impact of this is that it has improved patient experience and the service is gaining widespread recognition. Future work includes more open evenings for lesbians, attending Bristol LGBT Pride in 2015 and more open evenings being planned for lesbian women in 2015.

12 Annual Equality Report 2014/5 Cancer Services - Last year 39% of outpatients were female and 58% male and 6% describe themselves as Black or Ethnic Minority (BME). The annual National Cancer Patient Experience Survey for 2014 Survey showed significant improvement at NBT from 2013, the Trust was in the top ten of the most improving Trusts.

Key areas have been addressed like including verbal and written information, communication with patients; care provided by doctors, clinical nurse specialists (CNS) and ward staff, as well as support for people with cancer and the provision of information to patients regarding free prescriptions and financial advice.

NBT continues to lead nationally on cancer survivorship during 2014/2015 by building expertise and capacity in implementing alternative and holistic approaches to cancer aftercare.

September 2015 saw a key mile stone in the strategy to improve patient experience at NBT with the opening of the NHS Macmillan Wellbeing Centre at Southmead Hospital.

Women going through treatment for cancer were given an afternoon of pampering at the NGS Macmillan Wellbeing Centre in November 2014 when they were treated to a master class by beauty experts from charity “Look Good Feel Better”.

All cancer teams run regular “Living Well” events offering information and advice on health and wellbeing pre and post-treatment and signposting to local support services.

A number of cancer teams in collaboration with the psychology service also run self-management courses for patients.

Evaluations of these programmes indicate high levels of patient satisfaction and improved patient experience and outcomes.

During 2014/2015 there has been a funded pilot with Macmillan, trialling new roles to provide tailored support for cancer patients post treatment across Bristol. Therefore, 2 part time Cancer Support Workers were appointed to the NGS Macmillan Wellbeing Centre who provide face to face, telephone support and sign posting to services. These new roles have proved to be highly successful and crucial in the success of the Wellbeing Centre. They provide a useful template for the development of innovative and cost effective ways of providing support to cancer patients at NBT. The service is currently exploring a range of avenues to maintain and enhance these posts when the pilot ends.

The Trust is also participating in a project working with Prostate Cancer UK to further develop, embed and evaluate the survivorship programme in prostate cancer for men. The team is in the process of bringing about a service redesign in the approach to care and support for people affected by cancer. This involves implementing an integrated model of survivorship into the care pathway for everyone with a greater focus on recovery, health and wellbeing after treatment. Some of the teams have already implemented a risk stratification process to ensure more targeted and tailor-made follow up for patients following cancer treatment.

Care of the Elderly - NBT uses the “This is ME” a tool for people with dementia to complete that lets us know about patient’s needs, interests, preferences, likes and dislikes. This increases the quality of person centred as it improves understanding of the individual, which in turn promotes relationships.

Annual Equality Report 2014/5 13 Clinical Governance - The Trust is committed to making safeguarding a high priority and recognises that the requirement for safe practice needs to influence and drive all aspects of the Trust’s work and future developments. To that end a Safeguarding Committee was set up some years ago which is chaired by the Director of Nursing. This committee has responsibility for setting and monitoring the delivery of the Trust’s strategic priorities for safeguarding and providing assurance to the Board. NBT uses the World Health Organisation check list for safeguarding.

Clinical guidelines are used to ensure the best practice is implemented across the Trust this is supported by the Clinical Effectiveness strategy which focusses on the provision of high quality treatments or services in a way that allows patients to achieve the maximum health gain. Independent health needs are determined on the pre op assessment. To ensure the best care we use a Root Cause Analysis to check for things that may result in harm such as pressures sores, falls or anything else. These are used to try to identify why incidents it happen and to ensure learning from them. They involve a range of professionals e .g. nurses, physiotherapists, Occupational therapists and so on.

NBT uses the “This is ME” a tool for people with dementia to complete that lets us know about patient’s needs, interests, preferences, likes and dislikes. This increases the quality of person centred as it improves understanding of the individual, which in turn promotes relationships.

Where a patient become unruly we operate a red card system although we do not refuse to treat anyone.

Pastoral Care and Bereavement Services - Religious, spiritual and pastoral care is offered to patients, visitors and staff of all faiths or none and is a valued part of patient care within Southmead hospital. Chaplains help support those at some of the most distressing and challenging times of their lives. For those whose faith is important religious support is offered, helping to improve patients’ experience. A new space was created in the Brunel building called “the Sanctuary.”

The hospital has its own team of chaplains and volunteer pastoral visitors. The chaplains are from various Christian denominations and one is Gay. The wider team of volunteers also includes Buddhist, Hindu, and Muslim representatives. All members of the chaplaincy are happy to work with those of different traditions and faiths and those with none.

The chaplains regularly visit the wards and are always happy to see patients or visitors, to offer a ‘listening ear’. They are also available to pray with a patient or offer the appropriate religious support in an emergency.

The Patient Affairs (Bereavement Services) team provides the expertise to manage the legal and practical requirements following a death in hospital. Working closely with doctors, the wards and the mortuary, they manage the release of the deceased from the hospital to the appropriate people. Previously the team worked with the Muslim community to ensure the best support for families who lose a baby, which has been noted as excellent practice.

Beautiful bound books of remembrance for babies have been presented to the chaplaincy teams at Southmead by the Bristol branch of the stillbirth and neonatal death charity SANDS. These are placed in the Sanctuary at the heart of the Brunel building. The Rev Stephen Oram, Chaplaincy Team Leader for Bristol NHS trust said: “Books of remembrance for babies have been in place since the 1980s. It’s somewhere for families to come on anniversaries to reflect on their loss, to have a permanent reminder of their baby is very important for them.”

The Sanctuary is being used every day with a constant stream of individuals and groups wanting to pray or just have some peace and quiet.

14 Annual Equality Report 2014/5 Interpreting service - It is the policy of the Trust to provide all patients, whose preferred method of communication is not English, with appropriate access to information about Trust services, their treatment and care. Specific communication needs may be met by a range of approaches and are expected to evolve with increased use of technology. Face to face interpreting is only used in very specific cases. NBT uses trained interpreters from our approved suppliers to ensure:

Patients whose preferred method of communication is not English are involved in their care reducing anxiety and improving clinical outcomes

Fully trained interpreters are used to reduce clinical risks

Equal access to care packages and pathways is ensured

Confidentiality is maintained

There is no conflict of interest

In 2014 NBT provided British Sign Language interpreting on 320 occasions (average of 26 bookings per month). This is currently provided by South Gloucestershire Deaf Association.

Foreign Language interpretation is currently provided by “The Big Word.” 1,145 interpreters were provided by telephone (average 95 per month) and 1,693 face to face interpreters (average 141 per month). Directorates with highest usage are Women’s and Children’s Health, Surgery, Medicine and Children’s Community Health Partnership (CCHP). The most requested languages include Polish, Somali and Arabic.

Patient’s leaflets have been rationalised over a number of years and some of these are produced in easy read format which improves access for Disabled people and those whose first language is not English.

8 Facilities Management Access for disabled patients - Engagement was carried out in the early design stage of the Brunel building when the Bristol Physical Access Chain (BPAC) were asked to review the building design and suggest how Disabled people would best access the building. General issues were raised along with specific issues for hearing and visually impaired patients and for those with dementia. Many of the recommendations were incorporated into the design for example, a “changing places” toilet was installed on the ground floor so outpatients would have access to it, reception desks are fitted with hearing loops and lighting is good throughout the new building.

The BPAC members reviewed the Brunel building in September 2014 when they declared that they felt it is as accessible as possible, they were happy with the space in the accessible toilets as these give enough room for a wheelchair to turn round and for a carer to be present.

Fresh Arts Programme - The Fresh Arts 3 day Festival 2014 was created to celebrate the public art programme in the new Brunel building as well as to show patients, visitors and staff aspects of the on-going Fresh Arts programme through different workshops, performances, exhibitions and artists-in-residence schemes. The Festival created a chance for people to see the hospital as a positive resource, not just “a place for sick people”. It offered opportunities to try out creative activities, to give patients and staff a voice, to be a catalyst for expression and – above all – to make the building ‘sing’ with affirmative activity and life.

Annual Equality Report 2014/5 15 Lifelines project - This ran for the whole festival with a writer-in-residence which aimed to capture something their personal ‘lifelines’ – with a brief to work in clinical areas especially with patients who were isolated or long-stay, carrying the vitality of the programme up to the wards and bringing the creative voices of patients back down to the heart of the festival. Work was carried out with 25 patients and carers across 10 clinical areas who contributed to the process, wrote poems and generated lively conversations with a lot of smiles and laughter. The 47 lifeline poems written were displayed in the concourse. The poems created speak of human warmth, the joy of nature and the energizing and soothing impact of hobbies such as music and gardening, of the love and support of family and friends; patients spoke highly of the hospital environment. On several occasions one lady brought a sheaf of poems she’d just written and performed them with great passion, moving her listeners to tears. Putting into words complex and painful feelings about her husband’s dementia appeared to have been cathartic and helpful to her, as did the powerful effect of being heard. Other initiatives include:

Dementia and Care of the Elderly patients:

Knit With Me project weekly from July 2014 with patients in Elgar House, Community engagement in knitting Twiddlemuffs for dementia patients involving local knitting groups such as Southmead Community Centre Knit and Natter, Milestones Trust, Westbury on Trym Church knitters, staff knitting group Music performances including monthly evening concerts in the Sanctuary focussed on Complex Care wards and longer stay patients who are experiencing isolation in single bedrooms, plus regular ward visits Giant Jumper Lifelines creative writing project during monthly from January 2015, including dementia patient carer engagement Eating Disorder clinic patients Knit With Me six week knitting project

Schools:

Bristol Schools Chamber Choir, Horfield Primary School, St Teresa’s Primary School (Monks Park) and St Mary’s Primary School (Bradley Stoke) performed as part of the Fresh Arts Festival, October 2014 Exhibitions at gate 36 OP clinic by two local schools, Henbury School GCSE pupils and Fonthill Primary Artist’s commission with Horfield Primary School on local distinctiveness and sense of place

Volunteer Service - The Volunteer Service, comprises people drawn from a diverse background, it introduced “Move Makers” who are available near the check-in points and reception to offer assistance to any patient. This service proved highly effective immediately after the move into the building and has continued since.

16 Annual Equality Report 2014/5 Volunteers are provided as Befrienders, to the Chaplaincy, for help at mealtimes, BUST members (fundraising committee for the Breast Care Centre) League of Friends, Patient Panel, maternity, Wellbeing Centre plus Movemakers who comprise almost 39% of the total. 11% of volunteers come from a BME background. Training is offered to volunteers which includes that on equality, 44 volunteers attended this training in March 2014. 50 are on the list for the June 2015 training session.

Patient Experience Group (PEG) - This is chaired by the Director of Nursing and Quality with the aim of improving patient experience, working with the community and ensuring that the Trust puts patients at the heart of everything it does. Patient Experience Leads are nominated by every ward and they are responsible for taking the patient experience agenda out into the Directorates. PEG works closely with patient representatives and HealthWatch to ensure their views are represented. The Group is instrumental in analysing the Friends and Family Test results, other national surveys and patient feedback data from key patient involvement activities and making recommendations for action. The Trust has drawn up a new Patient Experience Strategy in consultation with staff, patients and carers groups including the Over Fifties Forum, NBT Respiratory Group, Rheumatology Support Group, Cardiac Rehab Group, Alzheimer’s Society, South Gloucestershire Equality Forum and the Carers Forum who have explored what exceptional patient experience looks like and how we can make it happen. Reconnecting with this wider audience has been invaluable in helping us to refresh our approach to delivering quality care. The strategy will be finalised later in the 2015. The Patient Experience Group has continued to meet to receive reports about patient experience and to participate in workshops on topics such as the Trust Strategy, the Patient Experience Development Framework tool. A patient representative from this group feeds back to the Trust’s Quality Committee. Over the last year our extensive programme of involvement and communication has continued to engage patients, carers and the local community in the development of the Brunel building. We have also been working hard to encourage involvement from a wide range of service users for the new Frenchay Health and Social Care User Group and interim solution in Elgar House. Also patients and carers are helping us to streamline our patient administration processes such as our customer care standards and communication channels. We have a range of other patient/user groups who make a significant contribution to the development of services across the Trust. These include the Rheumatology Patient Support, the Renal Forum and Cardiac Rehab Groups. Having a Foundation Trust membership has enabled us to work closely with our patients, service users and their carers and our public members. As of March 2014 the membership is 11,500 strong and their views help us shape our plans for how our hospital and community services are run.

Patient Panel - The Patient Panel has continued to meet and work with us on a number of audits and other activities it is chaired by a lay person and is involved in a number of activities within the Trust including sitting as patient representatives on various committees and taking part in data collection for audit purposes. The work of this and the Patient Experience Group is extremely valuable and the contribution of group members is very much appreciated. Patient Stakeholder Group - Members of this were drawn from the Foundation Trust membership and those involved in the Seldom Heard research (2010) who are representative of a diverse community. They received training on equality and the Equality Delivery System and assessed the Trusts performance on equality in 2014. Their comments have been incorporated into the Equality Objectives for 2015-2016. This group is now managed by HealthWatch. Patient Information Service - The Patient Information Service guarantees that information given to patients meets standards such as that for the NHS Litigation Authority and Care Quality Commission and ensures that as a Trust we comply with relevant and equality legislation of access for all. This improves our patient experience.

Annual Equality Report 2014/5 17 Reception Service - A complaint was received from a blind patient who required his appointment details from every department in a format that could be read by his screen reader. Due to the amount of information on receptionist’s screens it is difficult to highlight this request. A new process was set up and a briefing paper explaining this was compiled, which includes the equiredr form for patients to agree to receive details in an electronic format, this is available on the intranet. A number of receptionists also underwent training with an external Visually Impaired (VI) trainer which they found highlighted a number of issues they need to take on board. A new patient record system is to be introduced later in 2015 which should deal with this situation more easily.

Patient parking - There is a contract with taxis to bring disabled patients to the parking area at the front of the hospital and for them to be accompanied to their destination in the hospital. This area is designated largely for them. However, a reasonable adjustment was made for a member of staff, who is a wheelchair user, who has also been allocated a space at the front door. There are 24 busses an hour that arrive close to the front door. A new car park, due to be finished in Spring 2016 will give greater access directly into the new building. Following complaints from patients that it was too far and too steep to walk from the current multi-storey facility a shuttle bus was provided. In January 2015 a new bus was brought into service, which has improved access for wheelchairs and all patients with mobility issues. Large size wheel chairs are available at the front door for patients to use free of charge. Future work - Visually impaired patients expressed a need for an audio guide to the new building and this is being explored with an external company. The costs have been identified and funding has been sought to provide this. Due to the distance in the Brunel building (280m, just under ¼ of a mile from one end to the other) a further adjustment is being made to provide a motorised buggy to transport patients. Some of the finance has been identified for this from charitable funds and it is hoped this will be introduced sometime in 2015.

Renal - The renal transplant team based in the Brunel building at Southmead hospital is in the forefront of a new initiative in delivering a patient pathway tailored to people with learning difficulties (PWLD) and complex needs who might not otherwise be able to undergo a life-changing procedure. The team work with relatives and carers to enable them to continue their role throughout the time spent in hospital. One-stop clinics are held to enable patients to meet healthcare professionals, such as anaesthetists and nurses who will be involved in their care ahead of the procedure so that they are better prepared for their time in hospital. The renal team have carried out several kidney transplants for people with complex needs in the last year and have about ten more awaiting transplants. To mark National Transplant Week Bristol theatre group “Misfits,” who themselves are PWLD, highlighted the work that goes on to support people who undergo kidney transplants. People who have already had kidney transplants and those waiting for an operation were invited to see “Misfits” perform in the atrium of the Brunel building. It is acknowledged that supporting people with complex learning difficulties to have transplants improves the quality of life for both the patients and their families.

Surgery - Endoscopy requests are now from GPs and based on clinical outcomes. This ensures the service does not treat patients differently based on their equality profile.

Vascular - a regional service is provided at all of the local hospitals so staff do the travelling thus 58% of patients were treated closer to home.

18 Annual Equality Report 2014/5 Women’s and Children’s Health - In 2014 the focus was on improving services for all women, including those with complications to improve their opportunities to experience a normal birth. Improvements were made to the birth centre at Southmead hospital to enhance the environment and increase capacity. This provides a relaxed environment with birthing pools, aromatherapy, massage, soft lighting, access to MP3 docking stations and the ability for partners to stay overnight. The environment of the labour ward has changed following DoH funding to improve privacy and dignity by building ensuite bathrooms, promoting use of the birthing pool, and launching a project called: “Keeping normality at the heart of complexity”. Nationally the majority of women give birth in an obstetric unit, leaving a minority of women using a birth centre or home. The model at North Bristol NHS Trust aims to start reversing the trend by supporting more appropriate women to give birth in a lower risk environment. Bristol’s first freestanding midwife-led birth centre opened at Cossham in 2013, promoting normality and providing wider choice for women. The Neonatal Intensive Care Unit (NICU) at Southmead hospital cares for about 700 babies a year, although not all of them need the support of the unit because they have been born prematurely. About 130-150 of the babies on the unit are born at less than 28 weeks. Staff, volunteers and parents celebrated World Prematurity Day in November 2014 as NICU was among one of the first units in the country when it was opened in 1946 by Dr Beryl Corner and has been providing pioneering care for premature babies ever since. 18 years ago babies born at 28 weeks were the ones that needed extreme support to survive now it is the babies being born at 23/24 weeks. The unit now has parent volunteers who support families when their babies are being cared for on the unit. Perinatal mental health has been identified as an area needing development, a new role has been developed to improve experience and outcomes for women who are known to have a mental health condition or suffer a foetal loss. Eastwood Park Prison service has an action plan on equality activities to develop the prison service. Maternity services have continued to ask questions regarding Female Genital Mutilation (FGM) and have ensured that this is asked as a mandatory requirement of all women who book in. The maternity data set has been updated to include the questions required for the Department of Health (DoH) and continues to be collected and sent to them as an integral part of the safeguarding process. A named person is leading on this work for the rest of the Trust. Health Visitors and GPs are advised when a baby girl has been born to a family where FGM has been practiced. A well-attended seminar day was held on this in March in conjunction with the DoH who funded it ensuring it was free for staff. Patient experience was captured in a postnatal survey/audit and in response to the patient Picker survey, which gave an assurance that women receive appropriate safe care provided by competent, caring staff. The post natal team have reviewed the survey and made changes to service delivery in response to women’s views. Staff awareness has been raised by posting Equality newsletters in departments, sending out information on Access to Work. Service users are involved in Maternity Clinical team interviews and Maternity Voices. All staff in maternity had an opportunity to engage on provision of future services. Equality matters are routinely included in training for all maternity staff.

Annual Equality Report 2014/5 19 9 How did we do? The statistics Patient Experience Feedback

The National Inpatient survey reported that:

78 percent of patients reported they were treated with respect and dignity

79 percent always had confidence and trust in doctors

94 percent said the room or ward was very/fairly clean

87 percent of patients said they always had enough privacy when being examined or treated

Family and Friends Test for Patients - The Friend and family test collects equality data which is helping us build a picture of our patient demographics. However, there is a need for a greater understanding among staff as to the importance of this.

Results from the Family and Friends Test for Patients (2013-2014) show that 94% of patients would recommend our inpatient and maternity services to their family and friends. Equality monitoring is carried out and this showed that responses came from 52% women, 48% men of which 3% are BME, 81% are White and 16% did not give an ethnic background. 27% stated they are disabled, 65% said they are non-disabled and 7% did not disclose this. 1% stated they are Lesbian, Gay or Bisexual, 51% heterosexual while 7% did not state either way. The largest age group (39%) to be treated were between the ages of 25 – 60 with 16% of people falling into each group 61 – 70, 71 – 80 and 81 and over. 7% did not state their age. It is difficult to pick up trends with one years’ set of data but this gives us a basis from which to start.

The information was useful in respect of an enquiry and a Freedom of Information Act request as it gave us additional information about how disabled patients receive our services.

During 2014-2015 the Friends and Family Test has continued for inpatients, maternity services, and the emergency department. Since January 2015 the test has been introduced to day surgery and outpatient departments.

We have improved response rates overall but struggled with specific areas at times.

Following a successful trial of electronic devices and video kiosks during March 2015 we are planning to expand the ways patients can give us their feedback.

The following shows one area where Trust has worked to gather information to improve patient:

Advice and Complaints Team (ACT) - A Complaints and Concerns Policy and Procedure was put in place in 2010 which aims to create a culture that encourages and welcomes patient and service user feedback and gives a commitment to avoid any discrimination against complainants. There were 1006 complaints and 4634 compliments thus complaints comprised only 18% of the comments received. 5 cases (15 in 2013) involved equality or dignity issues. No specific equality areas of concern were identified. Their annual report is presented to the Equality and Diversity committee.

20 Annual Equality Report 2014/5 10 Overall Assessment

Protected Characteristics - Lesbian and single women, Disabled and Trans people.

Bristol Centre for Reproductive Medicine (BCRM) - aimed to improve patient access and experience by extending the service to more lesbian women. A programme of outreach work was established with targeted open evenings for prospective lesbian and other patients together with existing BCRM service users, widespread advertising internally and externally and an increase in the promotion of alternative families on their website. The centre set up a Patient Group which includes heterosexual couples, lesbian couples and single women, reviewed all paperwork to ensure it is non- discriminatory, monitor and assessed referrals of lesbian couples and single women, brought in a Lead Nurse for the service for single women. This had an impact as the numbers of same sex couples increased from a very low number to 37 and single women to 40 and the quality of the service has been noted in feedback from patients. Patient experience was also improved for Disabled patient as new equipment was bought to assist them. Treatment was provided for a young patient undergoing gender reassignment. Services are offered to people undergoing gender reassignment procedures if they wish to preserve their fertility.

Protected Characteristics – Religion and Belief and non-belief Pastoral Care and Bereavement Services aim to provide religious, spiritual and pastoral care to patients, visitors and staff of all faiths or none to improve patients’ experience. The team is comprised of chaplains and volunteer pastoral visitors. The chaplains are from various Christian denominations and one is Gay. The wider team of volunteers also includes Buddhist, Hindu, and Muslim representatives. However, all members of the chaplaincy are happy to work with those of different traditions and faiths and those with none. The Patient Affairs (Bereavement Services) team provides a crucial service following a death in hospital, their work with the Muslim community at the loss of a baby has been noted as excellent practice. The outcome is that the new Sanctuary space is well used and the quality of the work is appreciated in feedback from patients.

Protected Characteristics – People with Learning Disabilities (PWLD) Renal - The transplant team aimed to improve the experience for (PWLD) and complex needs by instigating a patient pathway tailored to their needs. They worked with relatives and carers to enable them to continue their role throughout the time spent in hospital, organised one-stop clinics so patients could meet the healthcare professionals to better prepare them for their time in hospital. This was highlighted by a PWLD theatre group in the atrium of the Brunel building. The quality of life for both the patients and their families has been vastly improved by this work in Renal. This report gives evidence of how it meets the Equality Delivery System and works towards meeting the Public Sector Equlaity Duty. It gives an indication of some the high quality work within the Trust to ensure: “Better health outcomes” and “Improved patient access and experience.” This can be seen in BCRM with improved services for Lesbian and single women, Disabled and Trans people. The Interpreting service ensures that Deaf people have access to British Sign Language Interpreters and foreign language interpretation is available for patients whose first language is not English. The Facilities Directorate have a continuing relationship with Disabled people to ensure that access issues are dealt with, while Fresh Arts focusses on ensuring positive experience for patients, especial those who may be depressed or have dementia which also impacts on their families and

Annual Equality Report 2014/5 21 carers. The Volunteer Service provides much needed individual support to all patients and they have received training in equality which helps them to understand how best to approach patients who may require further support irrespective of their protected characteristic. Letters in different formats were produced for Visually Impaired patients and training was undertaken by reception staff to highlight the need for this. 58% of patients in Vascular were treated closer to home. The experience of pregnant women was improved becoming more holistic following updates to the birth centre at Southmead. A new role has been created to support women with perinatal mental health issues. Patient engagement is conducted in various ways and there is an extensive programme with patients who are Disabled, BME, over 50 and others which has brought changes to service delivery including streamlining the administration process. A diverse Patient Stakeholder Group gave comments which brought about changes in the equality strategy. The statistics show that 94% of patients would recommend our inpatient and maternity services to their family and friends. (Family and Friends Test for Patients 2013-2014). 78 percent of patients reported they were treated with respect and dignity. The Trust received over 5500 comments of which 18% were complaints of which less than 0.5% related to equlaity or dignity.

11 2014 Overview – Staff Aims and objectives - Our aims and objectives are in line with those of the Equality Delivery System: to have a representative and supported workforce and inclusive leadership which takes into account all the protected characteristics. There is extensive training and promotion of equality issues throughout the organisation to raise awareness of what is involved. Advice is available from the Equality and Diversity Manager and on the intranet equality pages. The main focus is on BME and Disabled staff as they have raised concerns and are the two groups who are shown to be the most dissatisfied in the Staff Attitude Survey. Other work is carried out on Sexual Orientation, Gender Identity and Religion or Belief and Age. The following shows some of the activities to achieve these overall objectives and to improve the satisfaction levels of BME and Disabled and other staff.

Black and Minority Ethnic Staff - Black and Minority Ethnic members of staff raised concerns about what they saw as a lack of career progression in the Trust. The statistics showed that the majority of BME staff are concentrated in band 5 and that very few are represented in higher grades. During Black History Month 2013 a meeting was held with the Director of People and Organisation Health who was impressed with the staff present. Consequently, mentors were offered by Board members and senior managers. Initially this offer was taken up very slowly due to the move to the new hospital however, 8 pairs were matched up over the period of this report. The BME Development Group was established, one of the members was elected as chair and the group grew by almost 40 members during 2014. All activities are promoted in the monthly Equality newsletter and electronically within the Trust. Over the next year it is looking at celebrating different cultures to raise awareness throughout the Trust. The Chief Executive agreed to meet with a small group of BME staff, with a non-executive Director and the HR Director, to listen to their stories and to take this work forward. A number of initiatives have been brought in to support BME staff which includes promoting secondment opportunities to group members, offering places as assessors at the assessment centres for the new Valued Based recruitment sessions, meeting with the Head of Employment Services who gave an insight into how the process works and recruitment skills training sessions. The recruitment of BME staff increased by 9% in 2014.

22 Annual Equality Report 2014/5 Training and courses are also offered and 1 member secured a place on the Mary Seacole programme. “Valued Manager” training was offered to managers to raise awareness. 3 members attended the NHS BME network conference in June 2014 and brought back a number of ideas which resulted in an action plan, most of which was completed last year. This work links with the Workforce Race Equality Standard which became mandatory on 1st April 2015. For Black History Month in 2014 an outside consultant facilitated a session and the group highlighted issues which they compiled into an action plan. One of these actions is how to build confidence and self-esteem. More recruitment skills training sessions are organised and staff will again attend the national NHS BME conference in June and a new plan of actions will be formulated. This is increasing confidence in BME staff and more are joining the Staff Development group. Two members who received mentoring secured permanent posts and a BME trainee gained a temporary post.

Disabled Staff - The Staff Attitude Survey (SAS) has shown for the last 5 years that Disabled staff are the most dissatisfied. The Electronic Staff Record shows just over 1% declare their disability status; this figure has not changed since 2009, in comparison with the SAS when 22% of those who completed forms in 2014 stated they are disabled. Continuous efforts are made to increase the statistics on the Electronic Staff Record for example all new staff are encouraged to provide this information when they attend Induction training. There have been some technical problems with this in that a self-service facility was introduced in 2014 which was intended to increase the collection of equality information. However, it then emerged that this does not record “disability.” This is a problem with a national system which has now been taken over by another company resulting in a further delay it is not known if this will be rectified for some time. This situation is outside the control of the Trust but the issue has been raised as it has an impact on how we measure the effectiveness of the actions we take as the figures on the ESR are very small and we cannot give data to show changes. Feedback from members of the Disabled Staff Development Group on initiatives taken so far are excellent.

Disabled Staff Development Group - A separate group was set up to support the development of disabled staff. Last year 14 new members were recruited to this group, a chair was elected and they met with the corporate Disability Champion. Concerns were raised about a number of policies for example, sickness and return to work and the need for a flexible working policy that encompasses disability. These are being looked at. Group members were also invited to be assessors at Valued Based recruitment sessions to enable them to understand the recruitment process at NBT. Feedback is that it is too early to see any big improvements but members recognise they can receive support from the Equality and Diversity manager, Ask HR and Occupational Health. The group calls for more awareness raising and training on disability issues throughout the Trust to highlight achievements, to look at good practice in other organisations and to undertake work to ensure that Disabled staff feel valued within the Trust and that their contribution is recognised. The group will consider the newly launched Bristol Deaf Charter and whether to recommend that NBT adopts it and produces an action plan to implement it in 2015. NBT’s Chief Executive has agreed to meet with a small group of Disabled staff, an Executive Director and the HR Director to listen to the stories of disabled staff and to take the disability agenda forwards

Trust Disability commitments - The Two Ticks Disability scheme was reviewed and re-awarded for a further year by Job Centreplus. The Mindful Employer charter (Mental Health for staff) is being developed by the Wellbeing unit. This project offers training throughout the year which is advertised to key managers.

Annual Equality Report 2014/5 23 Staff Equality group - This covers all the protected characteristics (race, sex, disability, sexual orientation, gender reassignment, religion or belief, including lack of belief and age). Members engage with the Trust commenting on policies and practices and organising equality events.

Equality Unit - Advice was given on a wide range of equality topics to departments and individuals across the Trust, these were mainly regarding staff. Of complaints received the majority were regarding disability issues, followed by race.

Employment Services - A number of initiatives are now established in Employment Services to support BME, Disabled, LGBT and other job applicants. The department monitors equality statistics to identify if there are any trends emerging across the Trust. Trust website signposts all job applicants to contact Employment Services for further assistance. This displays both the Two Tick Disability and Mindful Employer symbols. Arrangements are made when requested to support disabled applicants and ranges from providing coloured paper for dyslexics, increased time for testing and provision of equipment to attend interviews. Contact is made with professional organisations for advice when applicants require new adjustments and the best method of support is sought. Introduction of Value Based Recruitment. This is currently a pilot but has seen a significant increase in the number of BME staff recruited. The Job shop is based in the Brunel building giving greater access, support and job information to existing staff wanting a career change/progression and new visitors to the hospital looking for work. Assistant Director of HR and Head of Employment Services provided a bespoke session for BME staff as a result of issues raised by the BME Staff Development Group. BME and Disabled Staff invited to become assessors in the Value Based Recruitment Process.

New Starters Project - In 2014 the overall turnover rate for the Trust was around 10% higher than that for comparable trusts with some new starters reporting a negative experience which led to their decision to leave. A project was set up to identify, review and evaluate the experience of new starters in the Trust, find out why new starters were leaving, and give recommendations to improve their experience in order to reduce the turnover rate and improve working lives. Actions taken have already made a positive impact. Positive findings were that Employment Services are easy to make contact with and queries and problems were answered quickly and efficiently. Adequate programmes are in place to ensure that new starters are invited to formal inductions and in specialist areas. New starters stated they were made to feel welcome at induction programmes. Areas of excellence were found where new starters reported they felt supported and welcomed e.g. in the Emergency Department where a thorough and relevant speciality induction is planned for all new starters. Negative responses were that in some cases there was a lack of basic information like parking, IT, uniforms etc. although this may be a reflection of the amount of paperwork given to new starters. A number of recommendations were made and taken up which included the need for a clearer process for exit interviews which was carried out and an improvement seen in the quality and quantity of this feedback, including equality monitoring. Health Care Assistants are now recruited through the assessment centres and has resulted in an increase in the retention of staff. A need to speed up pre- employment checks saw contracts being sent with offer letters and approval of references being taken in Employment Services this process has improved timescales by a month, enabling earlier start dates. A pilot of on line Occupational Health checks means that these are being carried out more quickly and recommendations on how to reduce times for eligibility checks is being examined. There is an ongoing process of monitoring statistics over the year. 24 Annual Equality Report 2014/5 Standardised Shift Working Group - Following the move to the new hospital 12 hour shifts were introduced for nurses and has received mixed reactions. This group was set up by the Director of People and Organisation Health and the Director or Nursing and Quality, with the aim of: 1. Identifying current staff views regarding 12 hour shifts 2. Obtaining recommendations on how best to manage 12 hour shifts

As part of this work an engagement survey has been completed by over 850 staff to gain a better understanding of: Childcare issues Age related view Health conditions

The report and recommendations are due to be shared with staff in June 2015.

Promoting Equality issues - Equality newsletters were established and are now produced monthly, events are also promoted internally on the weekly e bulletin and the electronic notice board. Some items have been added to the monthly external HealthWatch electronic bulletin. Events are held during the year to mark Black History Month, International Men’s Day, Disability History Month, World AIDS Day, International Day Against Homophobia and Transphobia, Lesbian, Gay, Bisexual and Trans History Month when Peter Tatchell, Human Rights campaigner addressed a diverse group of staff, this was organised in conjunction with Unite the Union, Cheryl Morgan, a trans woman, facilitated a seminar when counsellors and a doctor attended among others, Chinese New Year and International Women’s Day (IWD) with an event hosted by the Director for Nursing and Peter Tatchell, Human Rights Campaign, Quality and a seminar facilitated by Kerry McCarthy, MP for Lesley Mansell, Equality and Diversity Manager, Phil Hedges, Chair Bristol NHS Bristol East. All of these are open to all staff except for the Branch Committee IWD event. Equality training is carried out throughout the year (see training section) and is given to all new staff at Corporate Induction; Consultants updates; Valued Manager for those on the Lead programme, and specific session like that on Aspergers was offered and very well attended.

Partnership Working - The Equality and Diversity manager has taken an active role with various external organisations and service users this has meant pooling expertise and resources to work on specific projects to benefit of patients, carers and staff for example: Diamond Cluster (BNSSG NHS Equality managers) Men’s and Boy’s Health Forum South Gloucestershire Council Gypsy, Roma, Traveller Group HealthWatch Patient Representatives LGBT Forum

The Equality and Diversity manager also provides advice and information to internal departments, groups and individuals like: Staff Equality Group Parking Services ASK HR Move project (Move to new hospital) Employment Services CAMHS (Children and Adolescent Mental Health Services) Fertility services Communications Department (including freedom of Occupational Health information requests) Facilities Management Students

Annual Equality Report 2014/5 25 12 Section Staff Services The Sanctuary (formerly the Chaplaincy) - The Sanctuary is a new space on the ground floor of the Brunel building. Feedback from staff is that they are very happy to have this fantastic new facility and support from the Chaplaincy staff who come from a variety of religious denominations, including one member who is gay. All staff will support anyone who approaches the service whether they have a faith or none. Staff are very happy to have this fantastic facility and support from the Chaplaincy staff. “Staff described the chaplaincy team as very accessible and caring.” CQC Feb 2015.

Christian Prayer Group - This group has 73 members of staff who are Christians and receive a weekly email with prayer points for workplaces across NBT, hospital and community services. A smaller group meets every Wednesday lunchtime to meet to pray and bless work areas. Feedback from members is that knowing other Christians means that they don’t feel alone in the work place, but part of a wider community. Members feel this helps to change difficult work situations and that prayers are answered e.g. issues with staff, complex discharges and seeing people’s health improve. They are considering adding extra days/times and social meetings to help more people to be involved in the group over the next year.

Muslim Prayer Space - On Fridays there is a congregation of about 40- 50 people including some women who attend Muslim prayers. The majority of them are Trust staff, some are patients and others are local residents. For daily prayers Muslims use the small room as staff come at different times throughout the day.

Staff Reward - A new project was set up in 2014 to look at Staff Rewards, a number were identified and a Staff Discount Brochure was produced. The Exit Questionnaire was rebranded and the form was reviewed, it now includes monitoring on disability, sexual orientation, religious belief and ethnic origin, indicators for discrimination, harassment, bullying, dignity and respect. This increased the amount of equality data captured. The form was also simplified for Facilities Management as many staff there do not have English as their first language. Managers and Staff Side reported this and there was an increased return rate on exit questionnaires. Staff are now asked where the Trust could have done better to support their disability and all staff who complete the form are given an opportunity to feedback on improvements.

Reward Interviews - Staff were interviewed in June 2014 from an identified equality group.

Staff Discount Brochure - Ideas were sought from the Staff Disability Group for discounts for them. 6 were negotiated which were included although identifying these was quite challenging. As a thank you, all the members of the Staff Disability Group received a personal copy of the brochure. The impact was more positive, as time was taken to listen, discuss and act on their behalf. A condensed fruit drink was distributed to all staff across the Trust including bank staff; the latter has a high population of BME staff.

Total Reward - Equality groups and the Sanctuary are actively advertised on Total Reward documentation, on posters in departments and on the intranet pages.

Future Work - The electronic staff record system gives staff access to some of their personal details which they can alter. The company who provides this is Iooking at how to include disability as this has been omitted.

26 Annual Equality Report 2014/5 Staff Wellbeing - The Trust offers a staff counselling service, provides relevant vaccinations for nurses and all staff are offered protection against flu. A new Well Being Project was introduced in 2014 and all initiatives have been promoted through the new Staff Wellbeing Newsletter, the revamped Zest4Life Intranet site and during Corporate Induction sessions for new staff.

Mental Health - The Trust signed up to the Mindful Employer Charter and this was promoted through: Occupational Health Service APOHS Breathing Space – Mindfulness meditation Health and Safety Stress awareness events Carers Liaison Team Happiness Project, promoted local mental wellbeing support and mental wellbeing sessions with staff across the Trust during October 2014 World Mental Health Day was celebrated with an information display

Community Outreach days raised awareness in the Brunel building via: Nilaari Agency, a community based mental health and complex needs support provider that administers accessible, high quality and culturally appropriate counselling, advocacy and support primarily to Black and Minority Ethnic (BME) adults and young people in Bristol who are experiencing mental health difficulties. Anyone can access their services Rethink, a charity who help millions of people affected by mental illness by challenging attitudes & changing lives

Staff Wellbeing Champion Network - This network began in 2014 and has over 400 members Trust wide. The aim is to raise awareness of wellbeing support and services and provides a link to the Champions work area to feedback on staff wellbeing concerns and suggestions for improvement to the Staff Experience team and managers. There is a focus on recruiting Wellbeing Champions who are over 50 years of age and ensuring a mix of champions from diverse communities. Men’s health - Set up and promotion of an NBT’s men’s football fitness training and team. Women’s Health - Jo’s Cervical Cancer charity – awareness raising. Celebration of International Women’s Day with free alternative therapy sessions for staff.

Money Advisory Service - This was set up to offer free unbiased advice to staff. It has proved very popular, increasing the number of sessions running from one day a month to two a month on the Southmead site and in the community. Feedback has been very positive, with the main demand on this service being for pension’s advice for those retiring/considering retirement.

Section Training - 3125 (44%) of staff undertook some form of equality and diversity training, attended corporate induction or used the E learning equality and diversity course. Many of these are new starters. This is an increase of 31% on the previous year. 2839 (39%) of staff went through iCARE training compared with 15% in 2013. Staff are made aware of how important it is to treat everyone fairly, equitably and with respect, dignity and compassion, in line with the Trust Values. All new staff are required to attend a Corporate Induction session which includes the Trust Values and equality matters. The Learning and Development department was evaluated and granted the Quality Mark by Skills for Health. The review specifically noted a high degree of quality in the equality section of the Corporate Induction training as it is positive and interactive.

Annual Equality Report 2014/5 27 Learning and Development provide training courses that include the protected characteristics like the Management Training Programmes, which emphasise the need for managers to treat staff fairly and equitably and cover all equality groups, Recruitment and Selection and Preventing and Dealing with Harassment and Bullying, Management Training Programmes, while the Mandatory Update Programme for Doctors includes responsibilities under the Public Sector Equality Duty. Appraisals were carried out for over 90% of staff and their assessment was that these were of good quality.

Preparation for Retirement courses are offered to staff who are retiring, the aim is to provide advice and guidance to help them to prepare their affairs effectively. 68 people attended these. Topics covered are: First thoughts on Retirement Health matters Adjusting to change Money matters and Wills Leisure in Retirement NHS pension scheme Keeping in touch with the NHS Safety and security in Retirement This course has been reviewed and four (one day) courses a year are held, offering 100 places. Currently these are oversubscribed. Feedback comments include: “Very good programme well organised and presented, good information friendly warm and approachable people providing presentations.” “Preparation for retirement has many facets – financial, Health, wellbeing, interests, changes in opportunity and the programme provides a good mixture of all of these elements very comprehensive presentations delivered on crucial subjects by well informed, credible people. Good mixture of knowledge and styles of presentation.”

Apprenticeship Schemes - Younger staff are supported to undertake these in the Trust to help them to develop skills and achieve qualifications. Apprenticeships are also provided for staff older than the typical specified age range for apprenticeships but these do not attract funding in the same way. Traineeships are offered to young people through Job Centre plus. Valued Manager Training was offered to managers and focussed on equality matters. This is being rolled out across the Trust in 2015 as it received exceedingly positive feedback and was welcomed by managers. Basic IT skills training offered to older members of staff for complete beginners and has proved very popular across Clinical Directorates, for Facilities Management and NBT Extra Bank staff. 23 staff have attended the course since it began and feedback is excellent. More are planned over the next year.

Section Headline Data for our workforce for 2014 The statistics show that BME staff are still predominately in band 5 (20%) and are underrepresented from bands 6-9 against the Trust BME workforce average of 13%. Women are 76% of the workforce but in senior posts (such as band 8D, 9, Consultants, Registrars and SAS Doctors) they represent 68% of this group (9% below the workforce figure) whereas the percentage for males is 31% (9% higher than that in the workforce). 1.17% of staff state they are disabled which is an underrepresentation against the National Staff Attitude Survey (SAS). Results for NBT in 2014 reported a total of 22% who declared they are disabled, an increase of 5% from the previous year. The Trust has 1.44% of employees who define themselves as Lesbian, Gay or Bisexual (LGB). This is a slight under-representation against the national data collected by the Office for National Statistics (ONS) which shows 1.5%.

28 Annual Equality Report 2014/5 Staff belonging to religions “Other” than Christian account for 7.5% of all staff which is an over- representation against the 2011 ONS data (0.5%). National research suggests that BME people and women are significantly underrepresented on NHS Boards at NBT 36% are female, 7% declare a disability. 14% are from a BME background this is higher than the percentage for Trust Boards in London (9%).

Recruitment - It does not appear that there are any immediate barriers to applicants with protected characteristics. The figures for 2014 show an increase in appointments of BME people and, although numbers are low for disabled and LGB applicants over 50% of those who applied were successful. For BME applicants almost 23% were appointed, an increase of 9% from 2013. 28% who applied were BME and 23% were appointed. Disabled applicants comprised just under 4% of the 19,000 applicants and of these almost 3% were successful. In 2014 there was an increase of 23% of leavers. Most of these are in the age range from 26 – 45. These figures reduce for age bands after 56-60. Less than 4% of applicants stated they were Lesbian, Gay or Bisexual and just over 3% of these were appointed.

Equal Pay - NBT has a robust job evaluation process which includes Staff Side representatives and managers who assess job descriptions, this is in line with Agenda for Change terms and conditions of employment. All jobs are assessed anonymously. Standardised pay scales and terms and conditions of employment are in place as per NHS Terms and Conditions Handbook and national medical staffing contractual arrangements. No cases of equal pay have been submitted to Employment Tribunal for a number of years. Further any changes to terms and conditions of employment are always negotiated with Staff Side.

Employee Relations - BME staff are represented in 8 of the 12 categories of cases raised with Ask HR which is lower than those of White staff who are included in 11. BME staff represent 15% of cases overall which is similar to the figure for 2011 and 2% higher than the BME workforce statistic. For disciplinary cases 38% were BME staff (25% more than the workforce figure) and 58% White staff, Harassment and Bullying cases concerned 29% BME staff and 57% White staff, grievances were raised by 18% of BME staff (5% more than the workforce figure) and 17% of White staff. It should be noted that these figures are calculated from the small number of cases registered in all these categories. There is a large amount of equality data missing from the Electronic Staff Record for disability thus there is only 1 case dealt with by HR (whistleblowing) involving a disabled member of staff. All new members of staff are encouraged to provide this information when they attend Induction sessions. 82% of cases were raised by women 4% higher than the female profile of our workforce compared with 15% from men which is 9% lower than in the workforce. The combination of data that was missing and those who did not define their sexual orientation represents 47% of staff who were managed under HR policies. 51% of these staff categorised themselves as heterosexual and 2% stated they are Lesbian, Gay or Bisexual in 2014 thus this figure has doubled since 2011 when it was less than 1%. There was a rate of 4% of LGB staff in disciplinary cases and 6% grievances. Overall figures are currently too small to be statistically significant.

Staff Attitude Survey Results - 20 categories were examined for equality impact from the 2014 survey, which itself had a very low response rate. It showed that BME staff fared better than White staff in 9 categories which is an improvement from 2014 as this represents an increase of 4 categories from 2013. Disabled staff showed lower results in 17 categories an increase of 2 categories since 2013. This was the largest equality group to respond (22%). Since 2009 this group have showed the most dissatisfaction. Women fared better in 13 categories than men. 51% of respondents said they are Christian, 38% had no religion, and other figures were too low to record. There were no recorded responses from LGBT staff. Annual Equality Report 2014/5 29 13 Headline Data 2014 The following headline data shows the diversity of staff at North Bristol NHS Trust between January 2014 and December 2014. The Trust now has this data from 2009 and the information is scrutinised by the Equality and Diversity Committee to monitor changes and highlight where action needs to be taken. Our Workforce

Workforce by Gender Workforce by Ethnicity

76% Black and Minority Female Ethnic Staff 13%

Male 24% White Staff 84%

Workforce by Disability Workforce by Sexual Orientation Lesbian, Gay, Disabled 1.17% Bisexual 1.44%

Non-Disabled 60% Heterosexual 55%

Did not say 39% Did not say 43%

Workforce by Religion and Belief Workforce by Age

Christian 35% 16-20 0.85% Atheist 7.5% 21-30 9% Muslim 1.15%

Hindu 0.47% 31-40 25% Buddhist 0.46%

Sikh 0.14% 41-50 26%

Jewish 0.09% 51-60 24% Jains 0.02%

Did not say 50% 61-70 4%

30 Annual Equality Report 2014/5 Family and Friends Test for Staff - The Family and Friends Test for staff is not disaggregated by protected characteristic and the information for 2014 showed that staff experience was very poor throughout the Trust. The survey method was electronic although some postcards were also distributed to supplement this (only 161 hard copy surveys were returned). Over the 3 quarters surveyed there were around 60% of respondents who said they were likely or extremely likely to recommend NBT to friends and family if they needed care or treatment and 41% who were likely or extremely likely to recommend it to friends and family as a place to work. Two additional questions asked were: What can be done to improve staff engagement/communication in your area? What can we all do to improve working lives here at NBT? Many of the issues raised in response to these questions were similar to those highlighted as concerns i.e. transport/communication/good line management/shifts/bed management. In response to the question around improving working lives, staff felt that there should be greater celebration of good practice and more positive feedback (as opposed to a focus on negative feedback). A set of actions were put into place to improve staff experience and the results for this test and are to be reported on later this year.

Harassment and Bullying - The harassment advice line service is confidential and independent. It was launched in November 2009 and is supported by staff who volunteer as harassment advisors, they are recruited from a diverse staff group. The service is continually reviewed and developed. In 2014 the helpline was moved to the equality office to encourage confidence and increase usage. There is a Trust wide policy that covers all protected groups. The policy is reinforced with a user guide for staff and managers which clearly identifies the process to follow to either resolve concerns raised informally or via formal investigation. The equality profile of users is reviewed annually and reported to the Equality and Diversity committee. Take up of the service is low and promotional messages are sent out throughout the year via electronic means, on posters and monthly in the equality newsletter. All new staff are informed at induction about the policy and service and are encouraged to report incidents. The Harassment and Bullying helpline received 17 calls which is a fall of 49% from 2013. There were 18% cases relating to BME and Disabled staff respectively, 6% for gender, none for LGBT, Religion or Belief or Age. The helpline is confidential and there are trained volunteers who offer support. However, there is more anecdotal evidence which suggests that this is not reported. There is regular advertising to staff about the services and new recruits are made aware of it during their Induction session and training is offered to managers on how to address this. In 2015 more advisers were sought and a number of staff applied to take on the unpaid role. They will undergo training later in the year. Protected Characteristics - Black and Ethnic Minority Our workforce figures showed the majority of BME staff concentrated in band 5, the Trust aims to have a representative and supported workforce so a number of initiatives were brought in. These opportunities have been taken up and more staff are joining the BME Development group which is helping to increase their confidence. Two members who received mentoring secured permanent posts and a BME trainee gained a temporary post. The workforce figures show that far more BME staff were recruited in 2014 a 9% increase from 2013.

Annual Equality Report 2014/5 31 Protected Characteristics – Disability To change the perception of Disabled staff in the Staff Attitude Survey a Disabled Staff Development Group was set up. A number of actions were taken and disability issues publicised. The monitoring figures are very low therefore it is difficult to evidence any impact at this early stage. However, feedback from the group is very positive. The Two Ticks Disability scheme was reviewed and re- awarded for a further year along with the Mindful Employer charter (Mental Health for staff). There was an increase in the number of staff recruited who are disabled and Employment Services take a number of steps to support Disabled applicants through the process. Protected Characteristics - Age Preparation for Retirement courses are offered to older staff while younger staff are supported to undertake Apprenticeship Schemes, some of these are also available to older staff. Traineeships are offered to young people through JobCentre plus. The impact is that younger people are being recruited and those retiring have found great benefit from the retirement course. Basic IT skills training sessions were offered to older members of staff who tend to have less confidence using a computer and they found this enormously helpful at work and in their daily lives. Protected Characteristics – Religion and Belief The new Sanctuary space offers support to staff with or without a religion or belief which includes specific prayer space for Christians and Muslims. There are volunteer chaplains who are Hindu and 1 is an Imam while another is Gay. All staff will support anyone who approaches the service whether they have a faith or none. Feedback from staff is that this service is valued. Chinese New Year has been celebrated for a number of years. Protected Characteristics – Lesbian, Gay, Bisexual and Trans (LGBT) Much is done to raise awareness of these through displays and seminars events to mark LGBT history month, World AIDS Day, International Day Against Homophobia and Transphobia and to highlight issues of harassment and bullying. All activities are open to all staff. Staff are also supported by previous actions which include two charters of 10 standards for Lesbian, Gay and Bisexual people and Trans people and guidelines to support staff who transition from one gender to another. Protected Characteristics – Race, Disability, Gender, Sexual Orientation, Gender Identity, Religion or Belief and Age These characteristics are all promoted throughout the year in the monthly Equality newsletters along with other internal electronic mediums to notify staff of all activities, give information about new developments and events. Quizzes have also been used to raise awareness. Equality training is carried out throughout the year or embedded within specific courses like that for Staff Recruitment which staff state is good quality and helps them to deliver their services. Overall Assessment Staff Training - The aim to ensure that training and development opportunities are taken up and positively evaluated by all staff was met in that 44% of staff undertook some form of equality and diversity training in 2014, an increase of 31% on the previous year. 39% of staff went through iCARE training a 24% increase from 2013. 17% of BME staff undertook some form of non-mandatory training which is 4% higher than the workforce figure for these staff and 3.5% more than in 2013. The Learning and Development department was the first to gain the Quality Mark by Skills for Health. The review specifically noted a high degree of quality in the equality section of the Corporate Induction training as it is positive and interactive.

32 Annual Equality Report 2014/5 Our aim to have a more representative and supported workforce is shown to have been met through the work for BME and Disabled staff. There has been a focus on Black and Minority Ethnic and Disabled staff over the last 15 months as members from both groups raised concerns about their development and the need to focus on making reasonable adjustments in terms of polices. Numerous training and other opportunities were offered and this is starting to show results for BME staff who have succeeded in securing permanent posts. The recruitment process has been reviewed and revamped which has resulted in an increased number of BME, Disabled and LGBT people being recruited. Further support is offered through the Staff Equality group and awareness is raised through equality events like those for Black, Disability and LGBT history months and International Women’s Day, while equality training covers all the protected characteristics. Other initiatives to support staff include the Staff Engagement and Well Being projects and the New Starters project. Staff have the opportunity to participate in religious worship in the Sanctuary and guidelines are being drawn up for staff regarding times to pray, fasting, dress code and religious festivals in 2015. Feedback from staff is very positive regarding all of this work for example the Harassment Helpline receives great reviews and more staff engage with the work of the Trust as a consequence. Section Corporate Achievements A measure of the quality of the work at NBT is shown through the numerous awards received which also impacts on service delivery and shows that patients are at the centre of what we do. Excellence in Practice award was given to Sister Anna Bell who set up the domestic violence service in the Emergency department two years ago. This was presented by South Gloucestershire Partnership Against Domestic Abuse, which is made up of the police, council, NHS and voluntary organisations, for demonstrating best practice in tackling domestic abuse. Staff have been trained in the types of questions to ask patients they think might be at risk of domestic abuse and there are two full-time Independent Domestic Violence Advisors working in the department. Clinical Pharmacy Congress Awards. Julie Hamer became clinical pharmacy technician of the year. She is the senior pharmacy technician at Southmead Hospital. The director of pharmacy Andrew Davies was shortlisted in the chief pharmacist of the year category. BMJ Awards in the Dementia Team of the Year Awards. The Memory Café was highly commended. Royal College of Midwives Annual Midwifery Awards. The trust, which runs maternity services at Southmead and Cossham hospitals, reached the finals for its work to support women who want to give birth in a low risk setting from hundreds of entries in the Excellence in Maternity Care category for its Moving Forward project, which set out to give women more choices about where they give birth. South West Fairtrade Business Awards. Southmead Hospital’s staff restaurant, the Vu, was presented with a silver award in recognition of its commitment to buy fairly traded products and also for the good work of the catering team in terms of raising awareness amongst staff about the products on sale which include bananas, tea, coffee, fruit juice and chocolate. The National Skills Academy Skills for Health Quality Mark was awarded to the Learning and Development department. The mark provides a framework that defines and endorses superior learning and training standards that healthcare employers need to cultivate a world-class workforce. NBT is recognised as a leading organisation for the education and training of healthcare and hospital staff. The Trust was assessed across its training portfolio and includes that for equality. The trust is one of just 16 organisations across the UK to receive the endorsement for delivering high quality training and the first hospital trust in the South West to achieve the standard.

Annual Equality Report 2014/5 33 South West Apprenticeship Awards. The Trust was named training provider of the year at the South West Healthcare Apprenticeship Awards in February 2014. Also acknowledged were: Advanced Level 3 Apprentice of the Year went to Allison Cooper, a trainee assistant practitioner. Three other apprentices from the trust were highly commended. Higher Level 4 Apprentice and Inspirational Apprentice, trainee assistant practitioner Oliver Milton- Newland was highly commended. Level 2 Apprenticeship in Payroll. Sarah Parsons was the first person in the Trust, and the country to complete this. Therapy Nurse of the Year 2014 Renal access nurse Wilfredo Manuel collected this award. A new service means that specialist nurses are trained in the practice of IV (intravenous) therapy. Southmead is the first hospital in the South West to have offered the service and it embeds good infection prevention and control and reduces waiting times. Estates and Facilities Innovation Award was secured at the Health Business Awards, which is a national award, in recognition of the work of staff and volunteers in undertaking the massive task of moving into the new Brunel building at Southmead Hospital Bristol. This highlighted the work of the MoveMakers (volunteers) acknowledging their work to support the move from the two hospitals at Frenchay and Southmead to the purpose-built new Brunel building. The award recognised the scale of the whole project, which saw the transfer of patients and staff over the course of two weeks, which was akin to a military operation and was carried out with the support of the RAF, Royal Marines Reservists as well as the ambulance service. Work Experience Quality Standard - NBT became the first NHS organisation to be given this honour. It is a national accreditation designed to recognise organisations with exemplary work experience provision; and also as a framework for development to help organisations plan, run and evaluate effective work experience programmes. The trust works with partners, including Job Centre Plus and schools and colleges to offer work experience placements. Care Quality Commission (CQC) inspections - This inspection took place in the run up to Christmas, the busiest period in the history of the NHS, not just in Bristol, but across the country and just a few months after the move from two hospitals into one. Every single service was rated as being “good” in the context of caring and Trust staff were described by the CQC as being “committed and passionate” and it was recognised that the caring nature of our staff runs through every one of our services “like a stick of rock”. However, its performance overall was seen as average and strategies were put into place to manage this. Cossham Hospital - Cossham Hospital passed all essential standards in its first inspection by the Care Quality Commission since its £19 million refurbishment. The 106-year-old community hospital in Kingswood reopened in 2013 and provides the area’s only stand alone midwife-led birth centre, renal dialysis unit, X-ray and scanning department, physiotherapy and outpatient appointments. Care Quality Commission inspectors found that the hospital was meeting all six standards during its unannounced visit in November and praised the high standards of cleanliness and said patients were positive about the standards of care. Community Children’s Health Partnership (CCHP) - CCHP services were rated as ‘Outstanding’ by the Care Quality Commission and described by inspectors as an “example of outstanding service nationally” for its commitment to involving children, young people and their relatives in planning and making decisions about their care. The service works in partnership with the Barnardo’s charity and provides all community child health and child and adolescent mental health services for Bristol and South Gloucestershire. It is a model that is unique nationally. “Most services that provide this type of care are delivered by different providers, for example social enterprises, mental health trusts or private providers,” says Dr Jane Schulte, the partnership’s director and a consultant community paediatrician, “but we are unusual in that we are partnered with a charity and overseen by an acute trust.

34 Annual Equality Report 2014/5 Emergency Department - Staff in the Emergency Department at Southmead Hospital Bristol were praised for their care and compassion by inspectors from the Care Quality Commission who highlighted the passion and team work of the department’s clinical staff as an area of “Outstanding Practice” in their report along with their “determination to provide high standards of care in the face of significant challenges”.

14 2015 – future challenges Since 2009 the Staff Attitude Survey (SAS) has shown that some areas are becoming worse, Disabled staff still represent the most dissatisfied group in the Trust, followed by BME staff, work is being undertaken to address this. However, far more is being done to promote equality, raise awareness and provide training. The impact of this work is that in the past year more BME, Disabled and LGBT staff have been recruited to the staff equality groups, there was a 29% increase in staff taking some form of equality training, career development for BME and Disabled staff is underway and reported cases of harassment and bullying are falling.

The Workforce Race Equality Standard and the Equality Delivery System are both mandatory and while we are confident that the work we do to support BME staff is having an impact we will continue to build on this. Similarly with the EDS, the Trust works hard to embed equality throughout the organisation and the challenge is to gather the information together to demonstrate the impact of this.

15 Conclusions and recommendations The Trust can evidence the work is does across the protected characteristics for patients, carers and staff. Patient satisfaction remains stable and the Family and Friends test showed that the majority would recommend NBT. Consultation is carried out in various departments with patients and much work is done for BME and Disabled patients, women and men, Lesbian, Gay and Bisexual and Trans patients and for those with a religious belief or none. In accordance with the Public Sector Equality Duty North Bristol Trust can show through its policies and practices that it endeavours to deliver the three aims of the General Duty. This report demonstrates some of the activities that are contributing towards removing or minimising disadvantages experienced by patients, carers and staff due to their protected characteristics and to tackling prejudice and promoting understanding between people who share a protected characteristic and others who do not. The Trust meets the Specific Duty, has set equality objectives for the four years from 2012 - 2016 and publishes this report to show compliance with the equality duty. Under the Equality Delivery System the Trust is found to be delivering positive outcomes for the 7 main protected groups, and is working towards continuous improvement. There is good engagement with patients, carers, communities and staff from protected groups to a greater extent. There is recognition of inequalities between protected groups and patients or staff as a whole. Information gathered is used to inform developments in services for all whether patients, carers or staff. The Trust has continued to work to ensure that equality of opportunity exists for all staff and has provided services to meet the requirements of people with different protected characteristics. Consultation was carried out with patients through the patient Experience Group and HealthWatch, they agreed the overall grade for 2014 is “Achieving” or Green under the Equality Delivery System 2. This shows that improvements are being made as NBT has moved up from the previous year when it was graded as “Developing” or Amber.

Annual Equality Report 2014/5 35 The initiatives taken up for BME and Disabled staff in particular will have further action plans devised in conjunction with staff to bring about positive changes. To reach the next level of EDS2 there needs to be an increase in the gathering of equality monitoring data, all departments need to ensure that they include equality actions in their business plans and report any actions taken on equality and detail these, together with the impact this has on people with different protected characteristics. This was agreed as a priority by the Equality and Diversity committee along with the need to raise more awareness and provide more training over the next year.

Lesley Mansell Equality and Diversity Manager Human Resources and Development Directorate Tel: 0117 414 5578 Email: [email protected] March 2015

Please contact us if you require this report in a different format.

36 Annual Equality Report 2014/5 16 Appendix A Abbreviations Annual Equality Report Glossary Term Definition

ACT Advice and Complaints Team BCRM Bristol Centre for Reproductive Medicine BME Black and Ethnic Minority BPAC Bristol Physical Access Chain (BPAC) CAMHS Child and Adolescent Mental Health Service CCHP Community Children’s Health Partnership CCGs Clinical Commissioning Group (replaced the PCT) CORC CAMHS Outcomes Research consortium CQC Care Quality Commission DoH Department of Health EDS Equality and Delivery System ESR Electronic Staff Record FFT Family and Friends Test GRMC Governance & Risk Management Committee GTR Gypsy/Traveller/Roma HR Human Resources IDDP International Day of Disabled People IWD International Women’s Day JSNA Joint Strategic Needs Assessment LEAD Leadership Development Programme LGBT Lesbian, Gay and, Bisexual and Trans NBT North Bristol NHS Trust PCT Primary Care Trust PROMPT Practical Obstetric Multi-Professional Training PSED Public Sector Equality Duty PWLD People with Learning Disabilities Staff Side Trade Union WAD World AIDS Day YPF Young People Friendly

Annual Equality Report 2014/5 37 Lesley Mansell Equality and Diversity Manager Human Resources and Development Directorate

0117 414 5578

[email protected]

March 2015 Please contact us if you require this report in a different format.

Report to: Trust Board Agenda item: 11

Date of Meeting: Thursday 31st March 2016

Report Title: National Staff Survey: Corporate Improvement Actions

Status: Information Discussion Assurance Approval

X X

Prepared by: Catherine Meredith, Head of Organisational Development

Executive Sponsor (presenting): Paul Jones, Director of People & Organisational Health

Appendices (list if applicable): Appendix 1: National Staff Survey Summary Report

Recommendation: The Trust Board is asked to: 1. Note the results of the 2015 National Staff Survey 2. Approve the three themes for corporate improvement resulting from this 3. Endorse the proposal that directorates hold engagement events with staff to explore themes emerging from the survey and agree two local improvement actions within their directorate, which make most difference to staff.

Executive Summary: The enclosed report provides a summary of the National Staff Survey conducted across the NHS during Autumn 2015. This year the Trust surveyed all eligible employees and achieved an improved response rate of 30% (25% in 2014 survey). This was the same response rate achieved at large teaching hospitals such as Oxford University Hospitals NHSFT, Barts Health NHS Trust and King’s College Hospital NHSFT. North Bristol NHS Trust

1. Purpose providing customised reports to Clinical Directorates based on their results. 1.1. The purpose of this report is to: http://www.nhsstaffsurveys.com/Page/1010/Home/N 1.1.1 Inform Trust Board of the results of the 2015 HS-Staff-Survey-2015/ National Staff Survey. 3. Results 1.1.2 Ask the Board to approve the three corporate improvement actions. In summary we have made considerable progress since last year’s survey: 2. Background 3.1. NBT is no longer in the worst 25% on any measure 2.1. The National Staff Survey was conducted across the in the survey NHS between September – December 2015. The 3.2. We are average or close to below average on most national response rate was 41%, down form the other measures. previous year. It was pleasing to note that the Trust managed to improve its response rate from 2014. 3.3. Whilst recognising the progress that has been made, the Trust aims to build on this position during 2.2. The Trust wishes to build on this position, through 2016, with high staff engagement scores to sustain 2016. With this aim in mind a methodology has been our good patient outcome measures. developed to action improvements to the 2015 National Staff Survey (NSS). This included 3.4. The Workforce Committee has considered lessons identifying three corporate themes for improvement learned from conducting the 2015 survey and action and asking directorates to identify two local recognised: themes to be agreed with staff following focus 3.4.1. The importance of engaging staff in agreeing groups. visible local improvement actions in each 2.3. There is extensive research, e.g. by Professor directorate which make most difference to Michael West that links the results of the staff survey staff. to improvements in patient outcomes, patient 3.4.2. Progress should be regularly monitored up to experience and financial viability of hospitals. and beyond the 2016 survey with more 2.4. The national summary of the NBT results is attached frequent mini pulse surveys to encompass the as Appendix 1. Further information is available from Staff Friends and Family Test. the NHS Survey website and the Trust will be

North Bristol NHS Trust

3.4.3. Staff should be updated regularly on in the past 12 months. Although this is in line improvements through the year, leading up to with average for similar Trusts, it is a position the next national survey period in autumn the Trust would wish to significantly improve. 2016. This will also help support high standards of employment practice and better performance 4. Corporate Improvement Actions management. 4.1. The results of the survey are set out in the appendices. 5. Recommendations 5.1. The Trust Board is asked to: 4.2. From a short list of improvement themes the following three have been recommended for 5.1.1. Note the results of the National Staff Survey corporate action across the Trust: as set out in the attached appendix • Communication with Senior Managers - 5.1.2. Approve the three corporate themes for through a visibility programme and improvement action engagement events across the Trust 5.1.3. Endorse directorates holding focus groups • Feeling Valued by Managers and the with staff to agree the two local themes for Organisation – with specific action to reduce improvement in each directorate. and eradicate bullying and improve coherence in staff recognition schemes • Improving the Reporting of Errors, Near Misses and Incidents – this will be combined with promoting the work of the Trust’s Speak Up Guardian to support a culture of open reporting and identifying barriers 4.2.1 Feeling valued by managers and the organisation was a key contributory factor where staff provided low scores. This will also build on the respect and dignity statement, ensure a robust zero tolerance approach to bullying and harassment (26% of staff reported bullying, harassment or abuse from colleagues

2015 National NHS staff survey

Brief summary of results from North Bristol NHS Trust Table of Contents

1: Introduction to this report 3 2: Overall indicator of staff engagement for North Bristol NHS Trust 5 3: Summary of 2015 Key Findings for North Bristol NHS Trust 6 4: Full description of 2015 Key Findings for North Bristol NHS Trust (including 14 comparisons with the trust’s 2014 survey and with other mental health / learning disability trusts)

2 1. Introduction to this report

This report presents the findings of the 2015 national NHS staff survey conducted in North Bristol NHS Trust.

In section 2 of this report, we present an overall indicator of staff engagement. Full details of how this indicator was created can be found in the document Making sense of your staff survey data, which can be downloaded from www.nhsstaffsurveys.com.

In sections 3 and 4 of this report, the findings of the questionnaire have been summarised and presented in the form of 32 Key Findings.

These sections of the report have been structured around four of the seven pledges to staff in the NHS Constitution which was published in March 2013 (http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution) plus three additional themes: • Staff Pledge 1: To provide all staff with clear roles and responsibilities and rewarding jobs for teams and individuals that make a difference to patients, their families and carers and communities. • Staff Pledge 2: To provide all staff with personal development, access to appropriate education and training for their jobs, and line management support to enable them to fulfil their potential. • Staff Pledge 3: To provide support and opportunities for staff to maintain their health, well-being and safety. • Staff Pledge 4: To engage staff in decisions that affect them and the services they provide, individually, through representative organisations and through local partnership working arrangements. All staff will be empowered to put forward ways to deliver better and safer services for patients and their families. • Additional theme: Equality and diversity • Additional theme: Errors and incidents • Additional theme: Patient experience measures

Please note, the questionnaire, key findings and benchmarking groups have all undergone substantial revision since the previous staff survey. For more detail on these changes, please see the Making sense of your staff survey data document.

As in previous years, there are two types of Key Finding:

- percentage scores, i.e. percentage of staff giving a particular response to one, or a series of, survey questions

- scale summary scores, calculated by converting staff responses to particular questions into scores. For each of these scale summary scores, the minimum score is always 1 and the maximum score is 5

A longer and more detailed report of the 2015 survey results for North Bristol NHS Trust can be downloaded from: www.nhsstaffsurveys.com. This report provides detailed breakdowns of the Key Finding scores by directorate, occupational groups and demographic groups, and details of each question included in the core questionnaire.

3 Your Organisation

The scores presented below are un-weighted question level scores for questions Q21a, Q21b, Q21c and Q21d and the un-weighted score for Key Finding 1. The percentages for Q21a – Q21d are created by combining the responses for those who “Agree” and “Strongly Agree” compared to the total number of staff that responded to the question.

Q21a, Q21c and Q21d feed into Key Finding 1 “Staff recommendation of the organisation as a place to work or receive treatment”.

Average (median) for Your Trust mental Your Trust in 2015 health in 2014 Q21a "Care of patients / service users is my organisation's 74% 71% 62% top priority" Q21b "My organisation acts on concerns raised by patients / 67% 72% 55% service users" Q21c "I would recommend my organisation as a place to 52% 54% 43% work" Q21d "If a friend or relative needed treatment, I would be 64% 59% 52% happy with the standard of care provided by this organisation" KF1. Staff recommendation of the organisation as a place to 3.64 3.65 3.32 work or receive treatment (Q21a, 21c-d)

4 2. Overall indicator of staff engagement for North Bristol NHS Trust The figure below shows how North Bristol NHS Trust compares with other mental health / learning disability trusts on an overall indicator of staff engagement. Possible scores range from 1 to 5, with 1 indicating that staff are poorly engaged (with their work, their team and their trust) and 5 indicating that staff are highly engaged. The trust's score of 3.73 was average when compared with trusts of a similar type. OVERALL STAFF ENGAGEMENT

This overall indicator of staff engagement has been calculated using the questions that make up Key Findings 1, 4 and 7. These Key Findings relate to the following aspects of staff engagement: staff members’ perceived ability to contribute to improvements at work (Key Finding 7); their willingness to recommend the trust as a place to work or receive treatment (Key Finding 1); and the extent to which they feel motivated and engaged with their work (Key Finding 4).

The table below shows how North Bristol NHS Trust compares with other mental health / learning disability trusts on each of the sub-dimensions of staff engagement, and whether there has been a change since the 2014 survey.

Change since 2014 survey Ranking, compared with all mental health OVERALL STAFF ENGAGEMENT Increase (better than 14) Average

KF1. Staff recommendation of the trust as a place to work or receive treatment (the extent to which staff think care of patients/service users is the trust’s top priority, would recommend their trust to Increase (better than 14) Average others as a place to work, and would be happy with the standard of care provided by the trust if a friend or relative needed treatment.) KF4. Staff motivation at work (the extent to which they look forward to going to work, and Increase (better than 14) ! Below (worse than) average are enthusiastic about and absorbed in their jobs.) KF7. Staff ability to contribute towards improvements at work (the extent to which staff are able to make suggestions to No change ! Below (worse than) average improve the work of their team, have frequent opportunities to show initiative in their role, and are able to make improvements at work.)

Full details of how the overall indicator of staff engagement was created can be found in the document Making sense of your staff survey data.

5 3. Summary of 2015 Key Findings for North Bristol NHS Trust

3.1 Top and Bottom Ranking Scores This page highlights the five Key Findings for which North Bristol NHS Trust compares most favourably with other mental health / learning disability trusts in England. TOP FIVE RANKING SCORES KF22. Percentage of staff experiencing physical violence from patients, relatives or the public in last 12 months

KF20. Percentage of staff experiencing discrimination at work in last 12 months

KF25. Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months

KF23. Percentage of staff experiencing physical violence from staff in last 12 months

KF21. Percentage of staff believing that the organisation provides equal opportunities for career progression or promotion

For each of the 32 Key Findings, the mental health / learning disability trusts in England were placed in order from 1 (the top ranking score) to 30 (the bottom ranking score). North Bristol NHS Trust’s five highest ranking scores are presented here, i.e. those for which the trust’s Key Finding score is ranked closest to 1. Further details about this can be found in the document Making sense of your staff survey data. 6 This page highlights the five Key Findings for which North Bristol NHS Trust compares least favourably with other mental health / learning disability trusts in England. It is suggested that these areas might be seen as a starting point for local action to improve as an employer. BOTTOM FIVE RANKING SCORES ! KF24. Percentage of staff / colleagues reporting most recent experience of violence

! KF28. Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month

! KF10. Support from immediate managers

! KF19. Organisation and management interest in and action on health and wellbeing

! KF9. Effective team working

For each of the 32 Key Findings, the mental health / learning disability trusts in England were placed in order from 1 (the top ranking score) to 30 (the bottom ranking score). North Bristol NHS Trust’s five lowest ranking scores are presented here, i.e. those for which the trust’s Key Finding score is ranked closest to 30. Further details about this can be found in the document Making sense of your staff survey data. 7 3.2 Largest Local Changes since the 2014 Survey This page highlights the five Key Findings where staff experiences have improved at North Bristol NHS Trust since the 2014 survey. (This is a positive local result. However, please note that, as shown in section 3.3, when compared with other mental health / learning disability trusts in England, the scores for Key findings KF4, KF17, KF28, and KF32 are worse than average).

WHERE STAFF EXPERIENCE HAS IMPROVED

KF4. Staff motivation at work

KF32. Effective use of patient / service user feedback

KF17. Percentage of staff suffering work related stress in last 12 months

KF28. Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month

KF1. Staff recommendation of the organisation as a place to work or receive treatment

8 3.2. Summary of all Key Findings for North Bristol NHS Trust

KEY Green = Positive finding, e.g. there has been a statistically significant positive change in the Key Finding since the 2014 survey. Red = Negative finding, e.g. there has been a statistically significant negative change in the Key Finding since the 2014 survey. Grey = No change, e.g. there has been no statistically significant change in this Key Finding since the 2014 survey. For most of the Key Finding scores in this table, the higher the score the better. However, there are some scores for which a high score would represent a negative finding. For these scores, which are marked with an asterisk and in italics, the lower the score the better.

Change since 2014 survey

9 3.2. Summary of all Key Findings for North Bristol NHS Trust

KEY Green = Positive finding, e.g. better than average. Red = Negative finding, e.g. worse than average. Grey = Average. For most of the Key Finding scores in this table, the higher the score the better. However, there are some scores for which a high score would represent a negative finding. For these scores, which are marked with an asterisk and in italics, the lower the score the better.

Comparison with all mental health in 2015

10 3.2. Summary of all Key Findings for North Bristol NHS Trust

Comparison with all mental health in 2015 (cont)

11 3.3. Summary of all Key Findings for North Bristol NHS Trust

KEY Green = Positive finding, e.g. better than average, better than 2014. ! Red = Negative finding, e.g. worse than average, worse than 2014. 'Change since 2014 survey' indicates whether there has been a statistically significant change in the Key Finding since the 2014 survey. -- Because of changes to the format of the survey questions this year, comparisons with the 2014 score are not possible. * For most of the Key Finding scores in this table, the higher the score the better. However, there are some scores for which a high score would represent a negative finding. For these scores, which are marked with an asterisk and in italics, the lower the score the better.

Change since 2014 survey Ranking, compared with all mental health in 2015 STAFF PLEDGE 1: To provide all staff with clear roles, responsibilities and rewarding jobs.

KF1. Staff recommendation of the organisation as a Increase (better than 14) Average place to work or receive treatment KF2. Staff satisfaction with the quality of work and -- ! Below (worse than) average patient care they are able to deliver

KF3. % agreeing that their role makes a difference to -- Average patients / service users KF4. Staff motivation at work Increase (better than 14) ! Below (worse than) average KF5. Recognition and value of staff by managers and -- ! Below (worse than) average the organisation

KF8. Staff satisfaction with level of responsibility and Increase (better than 14) Average involvement KF9. Effective team working -- ! Below (worse than) average KF14. Staff satisfaction with resourcing and support -- ! Below (worse than) average STAFF PLEDGE 2: To provide all staff with personal development, access to appropriate education and training for their jobs, and line management support to enable them to fulfil their potential. KF10. Support from immediate managers No change ! Below (worse than) average KF11. % appraised in last 12 mths No change ! Below (worse than) average KF12. Quality of appraisals -- ! Below (worse than) average

KF13. Quality of non-mandatory training, learning or -- Average development STAFF PLEDGE 3: To provide support and opportunities for staff to maintain their health, well-being and safety. Health and well-being KF15. % of staff satisfied with the opportunities for -- ! Below (worse than) average flexible working patterns * KF16. % working extra hours No change Average * KF17. % suffering work related stress in last 12 mths Decrease (better than 14) ! Above (worse than) average

* KF18. % feeling pressure in last 3 mths to attend work No change Average when feeling unwell KF19. Org and mgmt interest in and action on health / -- ! Below (worse than) average wellbeing

12 3.3. Summary of all Key Findings for North Bristol NHS Trust (cont)

Change since 2014 survey Ranking, compared with all mental health in 2015 Violence and harassment

* KF22. % experiencing physical violence from patients, No change Below (better than) average relatives or the public in last 12 mths

* KF23. % experiencing physical violence from staff in No change Below (better than) average last 12 mths KF24. % reporting most recent experience of violence No change ! Below (worse than) average

* KF25. % experiencing harassment, bullying or abuse No change Below (better than) average from patients, relatives or the public in last 12 mths

* KF26. % experiencing harassment, bullying or abuse No change Average from staff in last 12 mths KF27. % reporting most recent experience of No change ! Below (worse than) average harassment, bullying or abuse STAFF PLEDGE 4: To engage staff in decisions that affect them, the services they provide and empower them to put forward ways to deliver better and safer services. KF6. % reporting good communication between senior No change ! Below (worse than) average management and staff KF7. % able to contribute towards improvements at No change ! Below (worse than) average work ADDITIONAL THEME: Equality and diversity

* KF20. % experiencing discrimination at work in last 12 No change Below (better than) average mths

KF21. % believing the organisation provides equal No change Average opportunities for career progression / promotion ADDITIONAL THEME: Errors and incidents * KF28. % witnessing potentially harmful errors, near Decrease (better than 14) ! Above (worse than) average misses or incidents in last mth KF29. % reporting errors, near misses or incidents No change ! Below (worse than) average witnessed in the last mth KF30. Fairness and effectiveness of procedures for -- ! Below (worse than) average reporting errors, near misses and incidents

KF31. Staff confidence and security in reporting unsafe Increase (better than 14) Average clinical practice ADDITIONAL THEME: Patient experience measures KF32. Effective use of patient / service user feedback Increase (better than 14) ! Below (worse than) average

13 4. Key Findings for North Bristol NHS Trust 2635 staff at North Bristol NHS Trust took part in this survey. This is a response rate of 30%1 which is below average for mental health / learning disability trusts in England, and compares with a response rate of 25% in this trust in the 2014 survey.

This section presents each of the 32 Key Findings, using data from the trust's 2015 survey, and compares these to other mental health / learning disability trusts in England and to the trust's performance in the 2014 survey. The findings are arranged under seven headings – the four staff pledges from the NHS Constitution, and the three additional themes of equality and diversity, errors and incidents, and patient experience measures.

Positive findings are indicated with a green arrow (e.g. where the trust is better than average, or where the score has improved since 2014). Negative findings are highlighted with a red arrow (e.g. where the trust’s score is worse than average, or where the score is not as good as 2014). An equals sign indicates that there has been no change.

STAFF PLEDGE 1: To provide all staff with clear roles, responsibilities and rewarding jobs.

KEY FINDING 1. Staff recommendation of the organisation as a place to work or receive treatment

KEY FINDING 2. Staff satisfaction with the quality of work and patient care they are able to deliver

1Questionnaires were sent to all 8676 staff eligible to receive the survey. This includes only staff employed directly by the trust (i.e. excluding staff working for external contractors). It excludes bank staff unless they are also employed directly elsewhere in the trust. When calculating the response rate, questionnaires could only be counted if they were received with their ID number intact, by the closing date. 14 KEY FINDING 3. Percentage of staff agreeing that their role makes a difference to patients / service users

KEY FINDING 4. Staff motivation at work

KEY FINDING 5. Recognition and value of staff by managers and the organisation

KEY FINDING 8. Staff satisfaction with level of responsibility and involvement

15 KEY FINDING 9. Effective team working

KEY FINDING 14. Staff satisfaction with resourcing and support

STAFF PLEDGE 2: To provide all staff with personal development, access to appropriate education and training for their jobs, and line management support to enable them to fulfil their potential.

KEY FINDING 10. Support from immediate managers

KEY FINDING 11. Percentage of staff appraised in last 12 months

16 KEY FINDING 12. Quality of appraisals

KEY FINDING 13. Quality of non-mandatory training, learning or development

STAFF PLEDGE 3: To provide support and opportunities for staff to maintain their health, well-being and safety. Health and well-being

KEY FINDING 15. Percentage of staff satisfied with the opportunities for flexible working patterns

KEY FINDING 16. Percentage of staff working extra hours

17 KEY FINDING 17. Percentage of staff suffering work related stress in last 12 months

KEY FINDING 18. Percentage of staff feeling pressure in the last 3 months to attend work when feeling unwell

KEY FINDING 19. Organisation and management interest in and action on health and wellbeing

Violence and harassment

KEY FINDING 22. Percentage of staff experiencing physical violence from patients, relatives or the public in last 12 months

18 KEY FINDING 23. Percentage of staff experiencing physical violence from staff in last 12 months

KEY FINDING 24. Percentage of staff / colleagues reporting most recent experience of violence

KEY FINDING 25. Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months

KEY FINDING 26. Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months

19 KEY FINDING 27. Percentage of staff / colleagues reporting most recent experience of harassment, bullying or abuse

STAFF PLEDGE 4: To engage staff in decisions that affect them, the services they provide and empower them to put forward ways to deliver better and safer services.

KEY FINDING 6. Percentage of staff reporting good communication between senior management and staff

KEY FINDING 7. Percentage of staff able to contribute towards improvements at work

ADDITIONAL THEME: Equality and diversity

KEY FINDING 20. Percentage of staff experiencing discrimination at work in last 12 months

20 KEY FINDING 21. Percentage of staff believing that the organisation provides equal opportunities for career progression or promotion

ADDITIONAL THEME: Errors and incidents

KEY FINDING 28. Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month

KEY FINDING 29. Percentage of staff reporting errors, near misses or incidents witnessed in the last month

KEY FINDING 30. Fairness and effectiveness of procedures for reporting errors, near misses and incidents

21 KEY FINDING 31. Staff confidence and security in reporting unsafe clinical practice

ADDITIONAL THEME: Patient experience measures

KEY FINDING 32. Effective use of patient / service user feedback

Report to: Trust Board Agenda item: 12

Date of Meeting: 30th March 2016

Report Title: North Bristol NHS Trust Strategy 2016-2021

Status: Information Discussion Assurance Approval

Prepared by: Dr Chris Burton

Executive Sponsor (presenting): Medical Director

Appendices (list if applicable): Trust Strategy

Recommendation:

1. Approve the draft Trust strategy to go out to formal consultation

Executive Summary:

The Trust board has been in discussion about its 5 year strategy for 18 months. It was last discussed at a board workshop on 25th February 2016. The board has agreed a vision for 2020/2021 and chosen the 8 themes of work for realizing that vision.

Following the February workshop further work has incorporated the feed back received in to the document now presented for approval. The information on which the strategy is based is included in appendix 1 with specific information about diagnostic activity in appendix 2. The data set has also developed in detail since the workshop and is a live document with new information added as it becomes available.

Following approval of the document a period of formal consultation will commence. This will include both internal and external activities. Initially North Bristol NHS Trust a small number of focus groups with a range of staff will be undertaken to develop the tools for translating the Boards plans in to meaningful statements and language for people who work in the organization. Once these tools are in place events to introduce the strategy to staff and hear their feed back will be delivered.

External stakeholders have been identified with arrangements for engaging with them being planned.

The consultation plan will be put to the board in detail at its April meeting.

The board is asked to approve this strategy for consultation

NORTH BRISTOL NHS TRUST

2016/17 – 2020/21 STRATEGY

APPENDIX 1: DATA PACK TO SUPPORT STRATEGIC CHOICES

Version 1.4

18 February 2016

Contents

Page Executive summary 3

Introduction 7

Section 1: What are the future needs of the population we serve? 8

Local demographics and population growth predictions Local CCG priorities Age profile of NBT patients –trend over recent years

Section 2: How are we performing? 19

2.1Trust-wide activity 21 Activity and reference cost data – Trust-wide 29 - Surgery 32 - Medicine 40 - Neurosciences 52 - Renal 56 - Women & Children 58 - MSK 64 - CCS 68 - Specialised services 76

2.2 Financial data 81 2.3 Performance 90 2.4 Quality 94 2.5 Patient feedback 102 2.6 Staff feedback 102 2.7 Workforce 105

Section 3: What is expected of us? 108

3.1 NHS Five Year Forward View 108 3.2 Local CCG priorities 108

Section 4: How do we see ourselves? 110

4.1 Directorate input 112 4.2 NBT self-assessment 119

Executive Summary

The purpose of this document is to provide supporting information to the strategic objectives and direction of travel provided within the strategy. The information within this document includes finance, demographics, activity data input from clinicians and key stakeholders, and information on cross-cutting themes namely quality, performance, outcomes, patient and staff feedback and workforce.

Section 1: What are the future needs of the population we serve?

- The population served by NBT is growing and ageing - Activity within the Trust for those patients with long term conditions and multi- morbidities should be reviewed – for example work with commissioners on community service pathway development; adult and social care on community capabilities; reduce follow-ups; work with patients and clinicians to enable self-care; prioritise prevention within for example to pre-operative assessment unit - Cross-cutting clinical conditions should be taken into account within all Directorate priority setting and action planning for the next five years, namely taking into account mental health conditions, dementia, cancer survivorship, ensuring action involves engagement with key stakeholders - Cross-cutting issues such as alcohol harm reduction and inequalities should be taken into account within all Directorate priority setting and action planning for the next five years ensuring engagement with key stakeholders.

Relevance to strategic aims:

- Change how we deliver services to generate capacity to meet the demands of the future - Treat patients as partners in their care - Empower our clinicians to lead - Play our part in delivering a successful healthcare system.

Section 2: How are we performing?

Activity - key messages:

- Over the last 10 years there has been a 35% increase in emergency hospital admissions and a 65% increase in secondary care episodes for those over 75. There has been a continuous increase (2.6% p.a.) in urgent readmissions within 30 days of discharge from hospital (source Dr Foster SUS data). - Over the last 3 years increasing trends in elective activity are seen most notably in general surgery, plastics (following the hospital move),clinical haematology (following the hospital move), gastroenterology, clinical immunology and allergy, neurosurgery (following the move), nephrology (following the move), neurology, rheumatology, respiratory, spinal, general medicine. - Increases in activity also noted in this section for CT and MRI services. - Increased complexity of patients - Substantial fluctuations noted for adult mental illness - Nervous system admissions, skin surgery and renal procedures have remained fairly constant whilst activity in comparative trusts has increased. - Orthopaedic reconstruction and multiple trauma activity has increased in recent years and burns activity has decreased, most likely due to changes in specialised service provision determined regionally. - An opportunity exists to work with specialised services commissioners to review provision at NBT.

Relevance to strategic aims:

- Change how we deliver services to generate capacity to meet the demands of the future - Treat patients as partners in their care - Create a workforce for the future - Empower our clinicians to lead - Play our part in delivering a successful healthcare system

Finance – key messages:

- NBT’s Long Term Financial Model sets out the financial plan to 2020/21 - The 2016/17 Planning Guidance and NHS Five Year Forward View sets out Better Care Fund plans, the role of Health and Wellbeing Board and CCG Sustainability and Transformation Plan requirements which will have implications for system-wide funding streams which will require NBT engagement - NBT will continue to deliver services commissioned by two main CCGs and work with two community service providers - Reference cost index analysis identifies specific specialties which if moved towards achieving the national average would impact notably on reducing the Trust’s overall reference cost index. These include T&O, general surgery, neurosurgery and geriatric medicine

Relevance to strategic aims:

- Change how we deliver services to generate capacity to meet the demands of the future - Play our part in a successful healthcare system

Cross-cutting themes – key messages:

- Quality: the following priorities for improvement in quality will be detailed in individual directorate action plans. Quality improvement priorities to be considered by each directorate include 1. Improving care for patients with dementia 2. Improve our patient’s overall experience in hospital 3. Improving the recognition, diagnosis and treatment of Acute Kidney Injury (AKI) 4. Improving the quality and timeliness of information provided to GP’s when patients go home to ensure there is safe handover to primary care. 5. Reducing harm from infection 6. Dissemination of use of iCare 7. Reduction of pressure ulcers 8. Reduction of falls

- Performance: headline priorities include increasing patient flow and achieving performance targets notably in relation to ED, RTT and transfers of care and delivery against CQC inspection recommendations.

- National audits: Failure to maintain an effective National Clinical Audit programme and ensure that recommendations and actions are addressed within NBT. Areas identified where there is potential failure to protect patients from potential harm if there is a lack of robust and independent review of potential Clinical Alerts or issues of Clinical Concern that are identified or highlighted to the organisation

- Patient and staff feedback: further focus required on obtaining and responding to patient and staff feedback

- Workforce: Focus required on succession planning and appropriate skill mix.

Relevance to strategic aims:

- Change how we deliver services to generate capacity to meet the demands of the future - We will become one of the safest Trusts in the UK - We will increase our research contribution

3.What is expected of us?

Key messages:

- The NHS Five Year Forward View and 2016/17 NHS Planning Guidance sets the direction of travel nationally and requirements of local health and care systems - Stakeholder strategies and changing financial landscapes for the healthcare system as a whole (Better Care Fund) should be taken into account within directorate action plans for strategy implementation over the next 5 years.

Relevance to strategic aims:

- Play our part in a successful healthcare system

4. How do we see ourselves?

- Common themes relating to demand, productivity, capacity, workforce, quality and finance exist within all directorate plans for future priorities and service requirements. Common themes include the desire to develop specialist work, the need to work with stakeholders to improve patient flow and ensure patients receive the right care in the right place at the right time, and the need to support patients to enable self- management where appropriate - A move to increased cross-directorate planning is also highlighted in directorate plans for the future along with robust workforce succession plans and a focus on safety, quality, performance and research - Directorates are aware of common cross-cutting clinical themes that should be taken into account when planning for the future such as multi-morbidities, mental health, alcohol harm reduction and inequalities - Patient and staff feedback: further focus required on obtaining and responding to patient and staff feedback - An analysis of strengths, weaknesses, opportunities and threats by senior leaders within NBT identified a number of priorities including: o build on our areas of clinical excellence and specialist expertise o develop as a system leader to drive changes to service and pathway design – work proactively o lead on the research agenda o work with patients to enable self-management where appropriate o develop our workforce o improve our relationship with stakeholders o improve our information and intelligence function o improve our succession planning o identify and remain engaged in plans regarding health and social care budgets, specialised commissioning budget changes o engage in whole healthcare system planning regarding the NHS Five Year Forward View to manage issues such as increasing demand, public expectation and competition o ensure cross-directorate planning occurs where appropriate. Relevance to strategic aims:

- The key messages are relevant to all eight strategic aims.

Introduction

The purpose of this document is to provide supporting information to the strategic choices and direction of travel provided within the strategy. The supporting information within this document includes demographics; activity; finance; information on cross-cutting priorities namely quality, performance, outcomes, and workforce; and input from clinicians and key stakeholders including patients and staff.

By answering the following questions this document provides the thinking and analysis behind the development of the vision, values, strategic aims and objectives and ambitions set out within the Trust strategy:

What are the future needs of the population we serve?

How are we performing?

What is expected of us?

How do we see ourselves?

Section 1: What are the future needs of the population we serve?

Key messages:

and social care on community capabilities; reduce follow-ups; work with patients and clinicians to enable self-care; prioritise prevention within for example to pre-operative assessment unit - Cross-cutting clinical conditions should be taken into account within all Directorate priority setting and action planning for the next five years, namely taking into account mental health conditions, dementia, cancer survivorship, ensuring action involves engagement with key stakeholders

- Cross-cutting issues such as alcohol harm reduction and inequalities should be taken into account within all Directorate priority setting and action planning for the next five years ensuring engagement with key

stakeholders.

Relevance to strategic aims:

1.1 Local population growth predictions

Population of Bristol (Bristol Joint Strategic Needs Assessment, 2015)

The population of Bristol is around 442,500 people and is increasing. The population grew 11.8% since 2004 (compared to 8% in England and Wales) mainly due to the high number of births relative to deaths. This growth has been mainly concentrated in the inner city. The birth rate is high but has plateaued. The population is young, with a median age of 33.4 compared to 39.9 in England. There is a larger proportion of adults under 40 years old.

Around 16% of the population are from BME backgrounds but amongst children it is 28%. The city is increasingly diverse, with significant differences in ethnicity between areas.

There are 58,800 older people 65 and over in Bristol. This proportion (13.3%) is lower than nationally but has risen in the North & West (inner). There are projected to be 8,100 additional older people by 2022, a 14.2% rise.

Life Expectancy in Bristol has increased by 4.4 years for men and 3.2 years for women in the past 20 years. Despite the rise in life expectancy, Bristol is significantly worse than national average for men. Inequalities in life expectancy have not improved. The gap

between the most deprived and least deprived areas is 8.9 years for men and 6.6 years for women.

People in Bristol live for around 63 years in good health. Men have an additional 15 years in poor health and women have an additional 20 years in poor health. The number of years people are living in ill health has a vast range from 11 years to 31 years for females and from 10 years to 24 years in ill health for males. Premature mortality rates in some areas of Bristol are 3 times as high as other areas. Preventable mortality is reducing but there are still around 675 preventable deaths per year in Bristol. Dietary risks, tobacco and obesity are the biggest contributors to early death & disability

Infant mortality rates in Bristol are lower than the England average. More babies are born at a healthy birth weight than the national average but there remains inequality at a ward level. Breastfeeding initiation and continuation rates in Bristol are higher than nationally but within the city are lowest for women from White ethnic groups living in deprived wards. Maternal smoking rates at delivery are similar to nationally and are falling but there are very marked variations across the city.

Fifty-seven percent of the Bristol population are overweight or obese. Although the rate is lower than nationally and is relatively stable, since obesity is still a key factor in Type 2 Diabetes and coronary heart disease, this rate is of concern.

Bristol’s estimated level of smoking in adults has declined from 23.5% in 2010, to 18.9% in 2014 and is now similar to the England average of 18.0% but smoking-related deaths in Bristol remain significantly higher than the England average rate.

Alcohol-related and alcohol specific hospital admissions in Bristol are consistently higher than the national average, and have been rising. Alcohol-related deaths in men are significantly higher in Bristol (rate of 26 deaths per 100,000; national 16.6).

There are around 71,700 people in Bristol who report themselves as having a limiting long term illness or disability. In Bristol half of all premature deaths under 75 years are due to cancer and coronary heart disease (39% cancer, 11% coronary heart disease). These rates are lowest in the affluent

Whilst early deaths due to cardiovascular disease (CVD) in Bristol have been falling since 2001, rates are significantly higher than the England average and the rate for men is more than twice the rate for women

In Bristol, rates of early death due to cancer in both men and women have decreased since 2001, but remain significantly higher than the England average. More men than women die early from cancer. Screening coverage for breast, cervical & bowel cancer in Bristol are all significantly lower than the England average

Recorded crude rates of diabetes (5%) are lower than the national average (6.4%) but continue to rise in Bristol as in England overall. Recent estimates suggest that almost 10% of those over 16 years in Bristol have raised blood sugar levels and are at increased risk of diabetes.

Admission rates to hospital for all respiratory diseases are higher in Bristol than the England average. Recent data show that a third of all emergency admissions in Bristol, were for

respiratory conditions (an increase on the previous year). In Bristol, early death rates from respiratory disease are significantly higher than the England average and for the South West

Early deaths from liver disease in Bristol are significantly higher than in England. Rates are almost three times higher in men than women in Bristol. Most liver disease is due to alcohol, obesity and viral hepatitis.

30,100 Bristol patients (7.6%) received a diagnosis of depression in the last year by GPs. Rates have been rising across Bristol, and the highest rate is currently in the North & West (outer) area (9.3%). There were 1,600 attendances for deliberate self-harm at the Bristol Royal Infirmary in 2014. 18% made a repeated attendance during the year. This number has remained stable since 2011. There are around 500 admissions from self-harm for young people (10-24 year olds) in Bristol and this rate exceeds the England average.

An estimated 4,100 people in Bristol have dementia. Of these people, 68.7% have a diagnosis, compared with a national diagnosis rate of 66.1%. This number is rising in line with an ageing population.

Bristol’s hospital admission rates following a fall are significantly higher than the South West & England averages, and are increasing. The estimated health & social care costs of injuries following a fall are in excess of £11 million every year

Population of South Gloucestershire (South Gloucestershire JSNA 2016)

The age profile of South Gloucestershire’s population is broadly consistent with the national average, although the population age structure varies considerably across the district. Population projections are shown in table 1 and figure 1 below.

Table 1: Population projections for key age groups, South Gloucestershire 2013, 2018 and 2035

Age 2013 2018 2035 Growth from 2013 0-4 16,300 17,000 16,400 100 +0.61% 5-19 47,400 48,200 53,200 5,800 +12.24% 20-64 161,200 165,100 171,000 9,800 +6.08% 65+ 48,200 53,400 72,900 24,700 +51.24% 85+ 6,000 7,600 15,200 9,200 +153.33% All ages 273,100 282,700 313,600 40,500 +14.83% Source: ONS 2010 estimates

Figure 1:Population estimates (2002-2014) and projections (2012-2037), South Gloucestershire

Population Growth and Projection, 2002-2037 350000

300000

250000

200000

Persons 150000

100000

50000

0 2002 2007 2012 2017 2022 2027 2032 2037

Projection Estimate Population

Source: ONS 2012 subnational population projections and mid-year estimates 2002-2012

The population of South Gloucestershire has increased by nearly 10% since 2002 and ONS population projections suggest this is set to increase a further 17% by 2037 (Figure 2.) However these predictions do not take into account the significant housing developments taking place, which will likely swell the population further.

The age group that is set to make the largest proportional increases are those aged 65 and older with the number of 75 to 84 year old males predicted to double, the number of women aged 90 and over is set to triple and the number of males aged 90+ predicted to increase by five and half times current estimates (see figures 2 and 3).

Figure 2: Projected percentage increase in the populations of South Gloucestershire aged 65 and older

Percentage Increase in the Projected Populations of Older People

500% 450% 400% 350% 300% 250% 200% 150% 100% 50% 0% 2013 2015 2017 2019 2021 2023 2025 2027 2029 2031 2033 2035 2037

Males 65-79 Males75-84 Males 90 + Percentage increase 2012 baselinefrom Females 65-79 Females75-84 Females 90+

Source: ONS 2012-based Subnational Population Projections

Figure 3: Population pyramid for 2012 and 2037

South Gloucestershire Male & Female Population estimate 2012 and and Projection for 2037

90 + 85-89 80-84 75-79 70-47 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 -12,500 -10,000 -7,500 -5,000 -2,500 0 2,500 5,000 7,500 10,000 12,500

Males 2037 Males 2012 Females 2037 Females 2012

Source: ONS 2012-based Subnational Population Projections

Overall South Gloucestershire has good health outcomes, with high levels of life expectancy and relatively low levels of premature mortality compared with the regional and national average. Despite the relative affluence and good outcomes, there are still areas that require attention. In order to identify these areas, it is useful to review local data in a number of areas including risk factors, premature mortality and deaths considered preventable.

Despite the relative affluence levels of smoking, obesity and physical activity in South Gloucestershire are similar to the national average. Healthy life expectancy at birth for women has declined in recent years. Seventeen percent of adults still smoke, 25% are physically inactive, and 21% are obese. Eighteen percent of reception age children are overweight or obese, 11.2% overweight and 7.1% obese. Twenty-eight percent of year 6 children are overweight or obese, 14.7% obese and 13% overweight. Approximately 300 people each year die from conditions that are considered preventable. There has been little progress in reducing premature mortality in areas such as liver disease, respiratory disease and suicide.

The top causes of premature mortality under the age of 75 in South Gloucestershire for females are cancer (32.6%), ‘other’ (8.5%) and Coronary Heart Disease (5.3%). For males it is cancer (41.6%), CHD (14.9%) and ‘other’ (9.3%). There continues to be a considerable gap in life expectancy between deprived and affluent areas. The cause of death that contributes most to the life expectancy gap between the most and least deprived areas in South Gloucestershire for males is cancer (27%) and for women respiratory disease (28%). (Ref SG Prevention and Self-care Plan 2015).

Demand for planned care is affected by demographic growth, predominately the rise in the number and proportion of the population who are elderly population.

Changes in lifestyle will also impact on demand. In South Gloucestershire levels of physical activity remain low and around 60% of the adult population are either overweight or obese impacting on demand for planned services, particularly those related to musculoskeletal diseases. Although rates of smoking have declined, 17% of the adult population smoke. Outcomes for patients admitted to hospital who smoke are worse, with longer lengths of stay, higher rate of complication, decreased survival and increased risk of re-admissions.1

Changes in treatment practices, new drugs and development in equipment and surgical techniques affect the supply. Analysis of historical spending has indicated that new healthcare technology is one of the most important factors driving increased spend, contributing more than ageing and general demographic trends.

The vision for planned care in South Gloucestershire over the next five years is:

“South Gloucestershire CCG aims to offer a local health care service which means South Gloucestershire residents have access to the right care at the right time, close to home, which is efficient and effective.”

The key priorities for the next few years are set out in figure 4 and include:

- Prevention: To embed prevention and self-care along the planned care pathway, reducing or delaying the need for treatment where possible;

1 NICE public health guidance 48. Smoking cessation in secondary care: acute, maternity and mental health services. November 2013.

- Community: To provide care closer to home and in the community to help patients control their health choices; - Access: To enable South Gloucestershire residents to be able to access the right health care at the right time; - Choice: Provide patients with an informed choice of provider; - Quality: Continuously improve patient experience and clinical outcomes; - Efficiency: Minimising waste and maximising value by moving care into different settings and reducing procedures with low clinical value; - Collaboration: Working with the wider health and social care community to enhance the patient journey

Figure 4: South Gloucestershire CCG Planned Care Strategy priorities

Vision Principles Operational Priority Prevention • Signposting and self- • Maximise opportunities for To embed prevention management exercise within MSK services and self-care along • •

Integrate lifestyle Identify and address the planned care interventions in planned inequalities within the MSK pathway, reducing or care pathways pathway delaying the need for • Make every contact • Lifestyle interventions in pre- treatment where count operative management possible • Addressing areas of • Implement the South health inequality Gloucestershire Prevention plan Community • Pathway Development • Eye Care Pathways To provide care • Community Hospital • Working with providers to closer to home and in • Consultant services maximise capacity and the community to help delivered in community. availability of services within patients control their the community health choices. • Alternative approaches to OPD follow up attendances • Community pathways for ENT, dermatology, DVT and Urology Access • RTT • GP engagement in the To enable South • AQP development of referral dataset Gloucestershire • Access to services for dashboard, including referral residents to be able to minority communities rates and direct access access the right diagnostics health care at the • Demand and choice right time management - referrals tools for GPs, including Advice and Guidance Services, and referral guidelines • Community services, eg FGM Clinic • Focus on T&O demand and capacity, including interface service Choice • AQP • Improve data availability on Provide patients with • Waiting Times clinical outcomes including an informed choice of • Clinical Outcomes repeat procedures provider • Publish waiting times on the website Quality • Patient feedback • Monthly monitoring through the Continuously improve • Complaints Commissioner led quality Sub patient experience • PALs groups and escalation via and clinical outcomes. • Quality Portal ICQPM • Friends and Family • Focus on harm free care South Gloucestershire CCG aims to offer a local health care service which means South Gloucestershire effective. and which efficient home, is to close thetime, at right care to right access the have residents Test including clinical validation of

• Clinical outcomes waiting lists by providers • Assurance of provider actions relating to patient experience, including user and carer engagement • Focus on patient safety with local actions agreed with providers and partners. Efficiency • Length of Stay • Reduce low value procedures, Minimising waste and • Day Case rates with initial priority on reducing maximising value by • DNAs outpatient DNAs, increasing moving care into • Pre-elective bed days day case rates, and reducing different settings and • Interventions of limited first to follow up ratios. reducing procedures clinical value • Tariff rates for OPD procedures with low clinical value • 1st:follow up ratios vs day cases • High value orthopaedic procedures • Alternative approaches to OPD follow up attendances • Outcomes Based Commissioning (T&O Pathway) • Robust IFR policies that minimise the risk of a successful legal challenge and over performance of activity in the key treatment areas. Collaboration • Local Authority • Ensure systems for decision Working with the including Public Health making maximise opportunities wider health and • Specialist for collaborative working with social care Commissioning partners within South community to • Primary, Secondary, Gloucestershire enhance the patient and Community Care • Strengthen links between journey • BNSSG CCGs Clinical Leads for Planned Care • Voluntary/3rd Sector across BNSSG • APCRC

Figure 5 shows the projected increase in people aged 65 years and over with a limiting long- term illness up to 2030 and again highlights the significant increase over time.

Figure 5: South Gloucestershire population projections – over 65s with limiting long-term illness

Source: POPPI www.poppi.org.uk version 9.0 derived from Census 2001(‘a little’ / ‘a lot’ self-reported criteria used in Census)

Overall, as detailed in the Public Health Outcomes Framework, South Gloucestershire has one of the lowest rates in England for deaths from conditions considered preventable, for all ages (SG 140/100,000 vs England 188/100,000) and amongst the under 75 year olds (SG 58/100,000 vs England 81/100,000). South Gloucestershire has a higher prevalence of asthma, cardiovascular disease, chronic kidney disease and obesity compared to the England average (South Gloucestershire Council, 2015).

The prevalence of patients with multi-morbidities (long term conditions) is increasing in South Gloucestershire in line with national trends. A snap-shot of secondary care admissions for long term conditions patients with multi-morbidities is shown in figure 6.

Figure 6:

Numbers of long-term conditions in admitted patients in 2013 South Gloucestershire 2500

2000

8 or more

1500 7 6 5 4 1000 3 2 1

500

0 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Source: SWCSU local analysis of admitted patients

The vision for South Gloucestershire within the CCG’s Long Term Conditions Strategy is to: • Reduce the number of people developing a long term condition • Improve the quality of life of those diagnosed with a long term condition by offering tailored, holistic and patient-centred support using self-management as an enabler • Take a multi-morbidity approach to service provision for all patients with long term conditions rather than a traditional chronic disease-specific management approach.

2.2 Age profile of NBT patients

Figure 7: Age profile of NBT admissions, 2010/11 to 2014/15

North Bristol Trust - All Admissions - by Age Band 18000

16000

14000

12000 2010/2011 10000 2011/2012

8000 2012/2013 2013/2014 6000 2014/2015 4000

2000

0 0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 >90

Source: NBT

Figure 7 above shows that, as expected, we are seeing increases in the more elderly population with a steadily increasing trend in patients admitted who are aged 60 years or over. The number of patients 90 years and older is small but all increasing.

The above demographic data suggests not only a need to ensure services are designed to meet future population requirements but also highlights a need for strategic planning in relation to the Trust becoming a health promoting hospital and the associated co-ordinated actions for staff and patients (for example in relation to health promotion campaigns such as Smokefree Southmead, infection control, clinical governance and pre-operative assessment unit input).

Section 2: How are we performing?

2.1 Activity

Activity - key messages:

Relevance to strategic aims:

Finance – key messages:

- NBT will continue to deliver services commissioned by two main CCGs and work with two community service providers - Reference cost index analysis identifies specific specialties which if moved towards achieving the national average would impact notably on reducing the Trust’s overall reference cost index. These include T&O, general surgery, neurosurgery and geriatric medicine.

Relevance to strategic aims:

- Change how we deliver services to generate capacity to meet the demands of the future - Play our part in a successful healthcare system

Cross-cutting themes – key messages:

(AKI) - 4. Improving the quality and timeliness of information provided to GP’s when patients go home to ensure there is safe handover to primary care. - 5. Reducing harm from infection - 6. Dissemination of use of iCare - 7. Reduction of pressure ulcers - 8. Reduction of falls

- Performance: headline priorities include increasing patient flow and achieving

performance targets notably in relation to ED, RTT and transfers of care and delivery against CQC inspection recommendations. - National audits: Failure to maintain an effective National Clinical Audit programme

and ensure that recommendations and actions are addressed within NBT. Areas identified where there is potential failure to protect patients from potential harm if there is a lack of robust and independent review of potential Clinical Alerts or issues of Clinical Concern that are identified or highlighted to the organisation - Patient and staff feedback: further focus required on obtaining and responding to

patient and staff feedback - Workforce: Focus required on succession planning and appropriate skill mix.

Relevance to strategic aims:

- Change how we deliver services to generate capacity to meet the demands of the 20 future

- We will become one of the safest Trusts in the UK

Activity - Inpatient admissions Inpatient admissions and day case attendances have fluctuated since 2010/11. Non-elective admissions have shown a steady increase. Assumptions in relation to activity levels include the hospital move (May 2014) and centralisation of specific services (eg Vascular).

Figure 8: Inpatient admissions by type 2010/11 to 2014/15

Admission Type 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015

Day 43195 42293 43166 41509 38697

Inpatient 17287 15282 14263 14522 12042

Non-Elective 36034 35125 35718 38211 38890

Unknown 20517 21851 21258 21367 21866

Grand Total 117033 114551 114405 115609 111495 Source: NBT

Outpatient attendances by type: Outpatient attendances have fluctuated since 2010/11 with an increase in new outpatient appointments since 2013/14.

Figure 9: Outpatient attendances by type 2010/11 – 2014/15

Appointment Type 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 Follow Up 333454 316768 320960 327863 305852 New 138643 135240 137885 203519 197746 Non Face To Face Follow 1349 1214 165 5 150 Up Non Face To Face New 12 165 1 Unknown Appointment 3465 7115 9199 10892 10057 Type Grand Total 476911 460349 468374 542279 513806 Source: NBT

Non-elective activity

Analysis of Emergency Department (ED) activity from 2009 to 2014 indicates that, once ED diverts have been excluded, at a Trust-wide level overall attendances from 2009 to 2014 have been relatively stable (tailing off slightly post Brunel due to a drop in minor attendances) however the admission conversion rate has increased steadily (from around 16% to 24%), implying increased complexity (see figure 10).

There is a year on year increase in the proportion admitted, from 2009/10 average of 43% to 44.6% in 2010/11, to 49.4% in 2011/12, 57.1% in 2012/13, 59.3% in 2013/14. Monthly attendances appear to remain fairly consistent over the period. This trend could be driven by an increase in complexity of cases arriving via ED.

There has been around a 5% increase in the number of ambulance arrivals over the period (the increase experienced by the department is significantly higher than this due to the additional impact of diverts). The proportion of ambulance attendances admitted has risen significantly, from an average 49.6% in 2009/10 to 61.1% in 2013/14.

Both age groups 65-85 years and 85years+ show a clear increase in attendances over the period. Yearly the figures have grown steadily, from 929 in the 65-85 group in 2009/10 to 1,058 in 2013/14. An increase is also seen in the 85+ age group, from 326 in 2009/10 to 389

in 2013/14. For South Gloucestershire there is a very similar picture, with a 15.9% increase over the same period for 65-85 years and 29% increase in 85+ group.

The average age of ‘majors’ patients has decreased by half a year on average for all NBT patients. The average age of ‘majors’ patients over 85 shows a slight increase of a little over half a year.

Figure 10: Emergency Department activity

Average age of majors patients (excl under 18s and diverts) 64 62 60 58 56 200904 200906 200908 200910 200912 201002 201004 201006 201008 201010 201012 201102 201104 201106 201108 201110 201112 201202 201204 201206 201208 201210 201212 201302 201304 201306 201308 201310 201312 201402 201404 201406 201408

Total Linear (Total)

Average age of majors attendances over 85 91 90 89 88 87 86 200904 200906 200908 200910 200912 201002 201004 201006 201008 201010 201012 201102 201104 201106 201108 201110 201112 201202 201204 201206 201208 201210 201212 201302 201304 201306 201308 201310 201312 201402 201404 201406 201408

Total Linear (Total)

Source: NBT

The proportion of admits via ED has generally risen consistently over the period 2009-2014, from 39.6% in 2011/12 to 45% in 2013/14 (see figure 11). Although this proportion appears to decline following the hospital move this may be due to data quality issues and the over- recording of diverts.

At a Trust-wide level the most significant increases are seen in the 18- 65 age group (approximately a 13% increase over the period) with the 85 and over age group remaining reasonably static and 65-84 showing around a 5% increase.

Figure 11: Emergency Department admissions

Emergency admits and proportion via ED over time (Diverts counted as direct admits) 4000 60% 40% 2000 20% 0 0%

Emergency admissions Proportion via ED Linear (Emergency admissions)

Emergency admits by age band over time 2000 1500 1000 500 0 200904 200906 200908 200910 200912 201002 201004 201006 201008 201010 201012 201102 201104 201106 201108 201110 201112 201202 201204 201206 201208 201210 201212 201302 201304 201306 201308 201310 201312 201402 201404 201406 201408

18-64 65 - 84 Over 85

Average HRG tariff per emergency admission 2600 2400 2200 2000 1800 200904 200906 200908 200910 200912 201002 201004 201006 201008 201010 201012 201102 201104 201106 201108 201110 201112 201202 201204 201206 201208 201210 201212 201302 201304 201306 201308 201310 201312 201402 201404

Source: NBT

Top 15 specialties by elective activity over last 5 years

It should be noted that recent decreases in activity can in most part be attributed to the hospital move and centralisation of services such as vascular and urology.

Of the specialties with highest elective admission rates (over 2,000 admissions per annum) admissions have declined over the last 5 years (2010/11 to 2014/15) notably in gynaecology and urology. Admissions were lower in 2014/15 than 2010/11, with fluctuations on an annual basis, for general surgery, plastic surgery and T&O. Clinical haematology admissions have remained stable. Despite a decrease in admissions in 2012/13 there has been a steady increase in elective admissions for gastroenterology (see figure 12).

Of the specialties with elective admission rates of under 2,000 admissions per annum, admissions have declined over the last 5 years (2010/11 to 2014/15) in nephrology, neurosurgery and cardiology. Increases over the last 5 years can be seen in pain management, respiratory medicine and rheumatology. Neurology has remained consistent (see figure 13).

Figure 12: Top 15 elective specialties above 2,000 admissions per annum, NBT 2010/11 – 2014/15 Source: NBT

Figure 13: Top 15 elective specialties below 2,000 admissions per annum, NBT 2010/11 – 2014/15 Source: NBT

Activity and reference cost data by speciality

The following activity data (source Dr Foster) indicates:

- Outpatient activity showing number of attendances from October 2012-September 2015. - Elective activity for those specialties with over 500 spells over the last 3 years - Non-elective admissions by inpatient specialty showing number of spells from October 2012-September 2015.

Assumptions include the hospital move, centralisation of vascular services and transfer of children’s services.

Overall activity

Over the last 3 years outpatient activity has fluctuated month on month but a gradual increase in activity can be seen (16,761 attendances in October 2012 to 18,742 attendances in September 2015). The following data is summarised for specialties with a minimum of 130 spells over the course of 5 years (the majority of specialties). Elective activity over the last 3 years has remained fairly constant (5,386 admissions in October 2012 to 4,947 admissions in September 2015) with a reduction in activity during the period of the hospital move in 2014. Non-elective admissions have risen steadily over the last 3 years (4,887 in October 2012 to 5,481 in September 2015). See figures 14 to 16 for detail.

Figure 14: Trust-wide OP activity 2012-2015. Source Dr Foster

Outpatients Activity Trend

25000

20000

15000

Spells 10000

5000

0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 15: Trust-wide elective activity 2012-2015. Source Dr Foster

Elective Activity Trend - All NBT

6000

5000

4000

3000 Spells

2000

1000

0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 16: Trust-wide non-elective activity 2012-2015. Source Dr Foster

Non-Elective Activity Trend

6000

5000

4000

3000 Spells

2000

1000

0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Reference cost data (see table 2 below) shows the greatest difference in cost from national average costs for 2014/15 (NBT cost greater than national average cost) can be seen in CCHP, MSK, neurosciences and surgery. Renal and ‘unbundled services’ were lower than the national average cost in 2014/15.

Table 2: Directorate level reference cost data

National NBT Reference Reference average Directorate Quantum Costs Index Costs Index Quantum £m 2014/15 2013/14 £m CCHP 27.27 16.59 164 133 Core Clinical 49.93 45.87 109 103 Medicine 94.55 84.45 112 100 Musculoskeletal 61.55 49.40 125 104 Neurosciences 39.98 32.25 124 108 Renal 24.81 26.19 95 88 Surgery 79.28 68.71 115 96 Unbundled Services 41.49 46.12 90 118 Women & Children 49.78 48.50 103 100 Other smaller specialties 0.72 0.58 123 132 Grand Total 469.35 418.66 112 103

Source: NBT

Surgery

Key points regarding activity over the last 3 years for the Directorate are as follows, taken from data within figures 17 to 30 (source Dr Foster) and table 3:

- Outpatients o Overall decrease in general surgery activity o Increase in urology February 2013 then stable activity levels o Fluctuation in plastics with overall downward trend o Fluctuation in breast surgery outpatients with overall upward trend o Overall increase in dermatology outpatients o Increase in vascular surgery outpatients following centralisation o Burns surgery outpatients overall decreasing trend in activity. - Electives o Stable activity levels for general surgery with overall upward trend o Fluctuations in urology but overall stable activity levels o Lower activity post-hospital move in plastic surgery with recent upward trend o Increase in activity post-hospital move in colorectal surgery with recent downward trend. - Non-electives o Overall increase in general surgery and urology activity o Downward trend in plastics activity. - Reference costs o Fluctuations seen in costs at specialty level from 2013/14 to 2014/15. The majority were above national average reference costs in 2014/15 (excluding breast surgery) likely due to PFI costs and service transfers (eg vascular).

Outpatients

Figure 17: Outpatients Activity Trend - General Surgery

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 18: Outpatients Activity Trend - Urology

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 19: Outpatients Activity Trend - Plastic Surgery

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Figure 20: Outpatients Activity Trend - Breast Surgery

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Figure 21: Outpatients Activity Trend - Dermatology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 22: Outpatients Activity Trend - Vascular Surgery

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250 Spells 200 150 100 50 0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 23: Outpatients Activity Trend - Burns Care

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Electives

Figure 24: Elective Activity Trend - General Surgery

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500 Spells 400 300 200 100 0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 25: Elective Activity Trend - Urology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 26: Elective Activity Trend - Plastic Surgery

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 27: Outpatients Activity Trend - Colorectal Surgery

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Non-elective

Figure 28: Non-Elective Activity Trend - General Surgery

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 29: Non-Elective Activity Trend - Urology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 30: Non-Elective Activity Trend - Plastic Surgery

200 180 160 140 120

100 Spells 80 60 40 20 0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

In relation to reference cost data, whilst having the impact that has been seen elsewhere across the Trust particularly in relation to the PFI costs, surgery costs fluctuate most likely due to services transferring in and out of the Trust. Costs tend to be high in areas where activity has transferred out as a result of service activity reducing, which can be seen in table 3 below with vascular surgery.

Table 3: Reference cost data - surgery (source NBT)

National NBT Reference Reference average Directorate Reporting Specialty Quantum Costs Index Costs Index Quantum £m 2014/15 2013/14 £m Surgery Breast Surgery 2.51 3.05 82 119 Burns Care 2.10 1.90 110 60 Colorectal Surgery 1.56 0.95 164 104 Dermatology 1.22 1.03 118 103 General Surgery 34.26 28.94 118 91 Plastic Surgery 15.78 14.45 109 95 Upper Gastrointestinal Surgery 0.32 0.23 140 92 Urology 20.70 17.54 118 106 Vascular Surgery 0.84 0.62 136 101 Surgery Total 79.28 68.71 115 96

Medicine

Key points regarding activity over the last 3 years for the Directorate are as follows, taken from figures 31 to 51 (source Dr Foster) and table 4:

- Outpatients o Notable increasing trend in hepatology and gastroenterology o Stable activity in cardiology with recent upward trend o Downward trend in respiratory and geriatric medicine activity o Fluctuations in adult mental illness with overall downward trend o Fluctuations in endocrinology activity but stable overall. - Elective o Increase in general medicine and gastroenterology activity o Fluctuations in cardiology activity o Increase in respiratory activity with recent fluctuations o Notable fluctuations in adult mental illness activity. - Non-elective o Increase in general medicine and stroke activity o Fluctuations in A&E activity with an overall upward trend o Downward trend in cardiology, respiratory, diabetic medicine, infectious diseases and gastroenterology activity o Decline in geriatric medicine with recent upward trend. - Reference costs o The overall position for medicine deteriorated from a reference cost index of 100 to 112. The two areas of ward-related activity where costs are highest in comparison with the national average are within General Medicine and Geriatric Medicine. This is likely due to high activity levels in 2014/15 and therefore higher PFI-related costs. o Respiratory Medicine has seen a decrease in reference costs in comparison to the national average cost from 2013/14 to 2014/15.

Outpatients

Figure 31: Outpatients Activity Trend - Hepatology

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80 Spells 60

0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 32: Outpatients Activity Trend - Gastroenterology

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 33: Outpatients Activity Trend - Cardiology

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Figure 34: Outpatients Activity Trend - Respiratory Medicine

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 35: Outpatients Activity Trend - Adult Mental Illness

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 36: Outpatients Activity Trend - Geriatric Medicine

200 180 160 140 120

100 Spells 80 60 40 20 0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 37: Outpatients Activity Trend - Endocrinology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Elective

Figure 38: Elective Activity Trend - General Medicine

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 39: Elective Activity Trend - Gastroenterology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 40: Elective Activity Trend - Cardiology

100

50 Spells 40

0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 41: Elective Activity Trend - Respiratory Medicine

120

100

60 Spells

0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 42: Elective Activity Trend - Adult Mental Illness

15 Spells

0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Non-elective

Figure 43: Non-Elective Activity Trend - General Medicine

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 44: Non-Elective Activity Trend - Accident & Emergency

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Figure 45: Non-Elective Activity Trend - Respiratory Medicine

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 46: Non-Elective Activity Trend - Cardiology

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Figure 47: Non-Elective Activity Trend - Gastroenterology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 48: Non-Elective Activity Trend - Geriatic Medicine

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 49: Non-Elective Activity Trend - Stroke Medicine

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 50: Non-Elective Activity Trend - Diabetic Medicine

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 51: Non-Elective Activity Trend - Infectious Diseases

40 Spells 30

0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

In relation to reference costs the overall position for medicine deteriorated from a reference cost index of 100 to 112. The two areas of ward-related activity where costs are highest in comparison with the national average are within General Medicine and Geriatric Medicine. This is likely due to high activity levels in 2014/15 and therefore higher PFI-related costs.

Respiratory Medicine has seen a decrease in reference costs in comparison to the national average cost from 2013/14 to 2014/15 (see table 4).

Table 4: Reference costs - medicine

National NBT Reference Reference average Directorate Reporting Specialty Quantum Costs Index Costs Index Quantum £m 2014/15 2013/14 £m Medicine Accident & Emergency 3.82 2.28 168 143 Cardiology 9.56 8.66 110 96 Chemotherapy 0.89 1.64 54 66 Clinical Haematology 2.51 3.06 82 80 Clinical Immunology and Allergy 0.75 0.90 83 82 Clinical Psychology 0.23 0.23 96 87 Diabetic Medicine 1.81 1.55 117 97 ED 14.28 13.83 103 102 Endocrinology 0.47 0.45 103 103 Gastroenterology 8.13 6.38 127 101 General Medicine 24.17 21.66 112 92 Geriatric Medicine 13.94 10.01 139 99 HIV / AIDS 1.84 1.35 136 162 Infectious Diseases 2.14 2.16 99 83 Medical Oncology 0.32 0.27 117 85 MIU 0.39 0.30 132 117 Respiratory Medicine 9.30 9.72 96 108 Specialist Palliative Care 139 Medicine Total 94.55 84.45 112 100

Source: NBT

Neurosciences

Key points regarding activity over the last 3 years for the Directorate are as follows, taken from figures 52 to 58 (source Dr Foster) and table 5:

- Outpatients o Upward trend in neurology activity o Fluctuations in neurosurgery and clinical neuro-physiology - Elective o Fluctuations in neurosurgery with recent upward trend o Upward trend in neurology - Non-elective o Decrease in neurosurgery activity o Fluctuations in neurology activity. - Reference costs o Low numbers of specialist elective activity (procedures) and the inclusion of outsourced activity most likely have resulted in an increase in reference costs compared to the national average from 2013/14 to 2014/15. It should be noted that neurology national average costs have decreased, whilst the Trust’s costs have increased.

Outpatients

Figure 52: Outpatients Activity Trend - Neurology

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 53: Outpatients Activity Trend - Neurosurgery

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Figure 54: Outpatients Activity Trend - Clinical Neuro-Physiology

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250 Spells 200 150 100 50 0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Elective

Figure 55: Elective Activity Trend - Neurosurgery

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Figure 56: Elective Activity Trend - Neurology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Non-elective

Figure 57: Non-Elective Activity Trend - Neurosurgery

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Figure 58: Non-Elective Activity Trend - Neurology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

In relation to reference costs low numbers of elective activity (procedures) and the inclusion of outsourced activity most likely have resulted in an increase in reference costs compared to the national average from 2013/14 to 2014/15. It should be noted that neurology national average costs have decreased, whilst the Trust’s costs have increased.

Table 5: reference costs – neurosciences, source NBT

National NBT Reference Reference average Directorate Reporting Specialty Quantum Costs Index Costs Index Quantum £m 2014/15 2013/14 £m Neurosciences Clinical Neurophysiology 0.65 0.50 129 58 Neurology 8.42 6.49 130 111 Neurosurgery 26.22 22.06 119 112 Stroke Medicine 4.49 3.01 149 79 Transient Ischaemic Attack 0.21 0.19 110 82 Neurosciences Total 39.98 32.25 124 108

Renal – additional data requested from Claire Weatherall - haemodialysis attendances over past 3-5 years, peritoneal dialysis patient numbers, transplant numbers.

Key points regarding activity over the last 3 years for the Directorate are as follows, taken from figures 59 to 61(source Dr Foster) and table 6:

- Outpatients o Fluctuations in nephrology with recent downward trend - Elective o Reduction in nephrology activity post-hospital move, with recent upward trend - Non-elective o Fluctuations in nephrology activity. - Reference costs o The renal position overall has remained below the national average. This is a key area which is being investigated as there may be costs, particularly within Transplant Surgery, which should be allocated to other surgical specialties.

Outpatients

Figure 59: Outpatients Activity Trend - Nephrology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Elective

Figure 60: Elective Activity Trend - Nephrology

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Non-elective

Figure 61: Non-Elective Activity Trend - Nephrology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Regarding reference costs the renal position overall has remained below national average. This is a key areas which is being investigated as there may be costs, particularly within Transplant Surgery which should be allocated to other surgical specialties.

Table 6: Reference costs - renal

National NBT Reference Reference average Directorate Reporting Specialty Quantum Costs Index Costs Index Quantum £m 2014/15 2013/14 £m Renal APD 0.80 0.91 88 81 CAPD 0.86 0.73 117 97 Home Dialysis 0.71 0.77 92 71 Hospital Dialysis 3.02 2.88 105 113 Nephrology 9.27 8.85 105 102 Satellite Dialysis 6.99 8.69 80 73 Transplantation Surgery 3.17 3.36 94 72 Renal Total 24.81 26.19 95 88

Women & Children’s Clarification requested from Ian Triplow as to whether obstetrics just number of births or other activity included.

Key points regarding activity over the last 3 years for the Directorate are as follows, taken from figures 62 to 71(source Dr Foster) and table 7:

- Outpatients o Increase across all specialties – gynaecology, midwife episode, obstetrics and community paediatrics - Elective o Fluctuations in gynaecology - Non-elective o Increase in obstetrics and gynaecology o Fluctuations in midwife episode, well babies and neonatology. - Reference costs o There has not been a significant increase in costs due to the majority of activity taking part in the Southmead retained estates, therefore it has not attracted the PFI costs. Work has been carried out during the year on the balance of activity between Gynaecology and Obstetrics and this is reflected in the changes seen in performance in these areas.

Outpatients

Figure 62: Outpatients Activity Trend - Gynaecology

2,000 1,800 1,600 1,400 1,200

1,000 Spells 800 600 400 200 0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 63: Outpatients Activity Trend - Midwife Episode

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500 Spells 400 300 200 100 0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 64: Outpatients Activity Trend - Obstetrics

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 65: Outpatients Activity Trend - Community Paediatrics

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Elective

Figure 66: Elective Activity Trend - Gynaecology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Non-elective

Figure 67: Non-Elective Activity Trend - Obstetrics

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Figure 68: Non-Elective Activity Trend - Midwife Episode

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Figure 69: Non-Elective Activity Trend - Well Babies

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 70: Non-Elective Activity Trend - Neonatology

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 71: Non-Elective Activity Trend - Gynaecology

100 90 80 70 60

50 Spells 40 30 20 10 0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

In relation to reference costs there has not been a significant increase in costs within Women’s and Children’s, due to most of their work taking part in the Southmead retained estates, therefore it has not attracted the PFI costs. Work has been carried out during the year on the balance of activity between Gynaecology and Obstetrics and this is reflected in the changes seen in performance in these areas.

Table 7: reference costs – W&Cs. Source NBT

National NBT Reference Reference average Directorate Reporting Specialty Quantum Costs Index Costs Index Quantum £m 2014/15 2013/14 £m Women & Children Community Midwifery 0.81 1.26 64 65 Gynaecology 11.81 9.89 119 111 Midwifery 10.31 11.34 91 93 Neonatology 0.10 0.13 73 241 NICU 12.10 8.80 138 118 Obstetrics 12.78 16.09 79 87 Other Specialist Nursing 0.32 0.15 215 241 Physio 1.55 0.84 185 185 Women & Children Total 49.78 48.50 103 100

MSK To discuss (24th Feb) with Carolyn Roper query raised re current gap re referral data and also inconsistency in the growth assumptions described in the directorate plan and the LTFM with respect to MSK.

Key points regarding activity over the last 3 years for the Directorate are as follows, taken from figures 72 to 77 (source Dr Foster) and table 8:

- Outpatients o Reduction in T&O o Fluctuations in rheumatology activity with recent upward trend - Elective o Downward trend in T&O with fluctuations o Increase in spinal activity o Fluctuations in rheumatology with recent upward trend - Non-elective o Fluctuations in T&O. - Reference costs o Musculoskeletal has seen an increase from 104 in 2013/14 to 125 in 2014/15. This is most likely due to a decrease in elective activity within 2014/15 along with an inclusion of outsourced activity within 2014/15 data analysis.

Outpatients

Figure 72: Outpatients Activity Trend - Trauma & Orthopaedics

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500

0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 73: Outpatients Activity Trend - Rhuematology

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Elective

Figure 74: Elective Activity Trend - Trauma & Orthopeadics

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0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Figure 75: Elective Activity Trend - Spinal

40 Spells 30

0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

Figure 76: Elective Activity Trend - Rheumatology

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100

Spells 60

0 Jun-15 Jun-14 Jun-13 Oct-14 Oct-13 Oct-12 Apr-15 Apr-14 Apr-13 Feb-15 Feb-14 Feb-13 Dec-14 Dec-13 Dec-12 Aug-15 Aug-14 Aug-13

Non-elective

Figure 77: Non-Elective Activity Trend - Trauma & Orthopaedics

250

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0 Jun-13 Jun-14 Jun-15 Oct-12 Oct-13 Oct-14 Apr-13 Apr-14 Apr-15 Feb-13 Feb-14 Feb-15 Dec-12 Dec-13 Dec-14 Aug-13 Aug-14 Aug-15

In relation to the reference cost index musculoskeletal has seen an increase from 104 in 2013/14 to 125 in 2014/15. This is most likely due to a decrease in elective activity within 2014/15 along with an inclusion of outsourced activity within 2014/15 data analysis.

Table 8: Reference costs - MSK

National NBT Reference Reference average Directorate Reporting Specialty Quantum Costs Index Costs Index Quantum £m 2014/15 2013/14 £m Musculoskeletal Rheumatology 2.04 1.88 108 124 Trauma & Orthopaedics 54.96 44.09 125 101 Wheelchair Services 4.55 3.43 133 130 Musculoskeletal Total 61.55 49.40 125 104

Core Clinical Services additional data requested from Sharon Nicholson for pathology and interventional radiology (3 yr trend activity & spend)

Also query re clinical haematology – should be in medicine or CCS – with Ian Triplow.

Key points regarding activity over the last 3 years for the Directorate are as follows, taken from figures 78 to 88 (source Dr Foster) and tables 9 to 12:

- Outpatients o Increase in pain management and clinical haematology o Fluctuations in clinical physiology, clinical immunology and allergy, physio. o Fluctuations in dietetics with recent upward trend o Reduced activity levels in diagnostic imaging post-hospital move. - Electives o Increase in immunology and allergy and clinical haematology o Fluctuations in pain management. - Reference costs o CCS saw an increase in reference cost index of 6% from 2013/14 to 2014/15 resulting in the reference cost index being 9% above the national average in 2014/15. o At specialty level from 2013/14 to 2014/15 the reference cost index increased for ICU/HDU, pain management, physiotherapy and radiology. The reference cost index decreased for the same period for dietetics, direct access pathology, OT and speech and language therapy.

Outpatients

Figure 78: Outpatients Activity Trend - Pain Management

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Figure 79: Outpatients Activity Trend - Clinical Haematology

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Figure 80: Outpatients Activity Trend - Clinical Physiology

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Figure 81: Outpatients Activity Trend - Diagnostic Imaging

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Figure 82: Outpatients Activity Trend - Clinical Immunology And Allergy

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Figure 83: Outpatients Activity Trend - Physiotherapy

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Figure 84: Outpatients Activity Trend - Dietitics

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Figure 85: Elective Activity Trend - Pain Management

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Figure 86: Elective Activity Trend - Clinical Haematology

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Figure 87: Elective Activity Trend - Clinical Immunology And Allergy

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Trends in diagnostic activity

An increase in activity seen in CT, ultrasound and MRI activity over the last 5 years.

Figure 88: Diagnostic activity over time 2010/11 – 2014/15 (source NBT)

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200000

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150000 CT Ultrasound MRI Flouroscopy 100000 Mammography Nuclear Medicine Obstetrics

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0 2010/11 2011/12 2012/13 2013/14 2014/15

This chart shows the volume of radiology examinations over time; a pattern that shows a steady increase from 2011 to 2014 but a reduction in current year. Key areas of growth are in CT (33% growth since 2010/11), MRI (20% growth) and nuclear (18% growth).

Table 9: Radiology data (source NBT)

ReportMod 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 Radiology (Plain 202922 205768 209127 216293 203308 Film) CT 48980 52408 56595 62078 65418 Ultrasound 50752 51740 52091 57535 55450 MRI 25004 26384 26904 29653 29912 Fluoroscopy 16375 17236 16980 16739 15946 Mammography 7384 7041 7045 12679 12245 Nuclear Medicine 4465 4344 4260 4972 5286 Obstetrics 4366 4903 4515 4762 4875 Grand Total 360248 369824 377517 404711 392440

Table 10: CT activity (source NBT)

Table 11: MRI activity (source NBT)

In relation to reference costs the position for CCS saw an increase of 6% from 2013/14 to 2014/15 resulting in the reference cost index being 9% above the national average in 2014/15. At specialty level from 2013/14 to 2014/15 the reference cost index increased for ICU/HDU, pain management, physiotherapy and radiology. The reference cost index decreased for the same period for dietetics, direct access pathology, OT and speech and language therapy.

Table 12: reference costs - CCS

National NBT Reference Reference average Directorate Reporting Specialty Quantum Costs Index Costs Index Quantum £m 2014/15 2013/14 £m Core Clinical Dietetics 0.26 0.49 53 73 Direct Access Pathology 7.41 7.14 104 107 ICU/HDU 20.56 20.19 102 97 Occupational Therapy 0.44 0.32 136 246 Pain Management 3.16 3.28 96 83 Physiotherapy 3.51 2.08 168 93 Radiology 14.24 12.03 118 114 Speech and Language Therapy 0.35 0.34 102 202 Core Clinical Total 49.93 45.87 109 103

Specialised services

National picture

Within England, Leeds Teaching Hospitals Trust has remained the biggest provider of specialised services, with specialised income of £415m – an increase of 6% on the previous year (see table 13). By comparison NBT earned £126.5m a reduction on the previous year of £9.9m (7.2%).

Table 13: Specialised services income by Trust

Provider Specialised % increase on services income 2013/14 (£m) Leeds Teaching Hospitals Trust 415.3 5.7% Guy’s and St Thomas’ NHS FT 383.7 4.9% Oxford University Hospitals FT 356.0 2.2% University College London Hospitals FT 349.4 4.1% The Newcastle upon Tyne Hospitals FT 342.6 4.6% Central Manchester University Hospitals FT 334.7 5.8% University Hospitals Birmingham FT 327.7 6.7% Barts Health Trust 316.1 4.7% Kings College FT 308.8 11.2% Sheffield Teaching Hospitals FT 295.9 3.7% Imperial College Healthcare Trust 288.0 0.9% University Hospital Southampton FT 262.2 14.1% Great Ormond Street Hospital for Children 261.4 3.5% FT Nottingham University Hospitals Trust 254.5 7.7% Cambridge University Hospitals FT 248.7 3.2%

There appears to have been little attempt to radically centralise services as the providers with the 10 biggest specialised budgets accounted for 31% of specialised spending in the acute sector compared to 30% in 2013/14.

Comparator data – major specialties

The following five-year trend data highlight the lack of growth in specialised services activity at NBT over recent years (see figures 89 – 95).

Figure 89: Neurosciences – against key national comparisons (NBT 19th largest)

Figure 90: Spinal surgery – against key national comparisons (NBT 28th largest)

Figure 91: Complex MSK – against key national comparisons (NBT 6th largest)

Figure 92: Burns – against key national comparisons (NBT 12th largest)

Figure 93: Plastics – against key national comparisons (NBT 17th largest)

Figure 94: Renal – against key national comparisons (42nd largest)

Figure 95: Major trauma– against key national comparisons (13th largest)

2.2 Finance

Key messages:

Relevance to strategic choices:

- Create a workforce for the future - Play our part in delivering a successful healthcare system

NHS Finance

‘Delivering the Forward View: NHS planning guidance 2016/17 – 2020/21’ (DoH, December 2015) describes an £8.4 billion real terms increase in funding for the NHS in England via the spending review (November 2015) by 2020/21. The guidance describes the 2016/17 ‘financial challenge’ for each trust will be dependent on end-of year financial outturn, and a continued focus on non-elective care. It describes local NHS systems as only being sustainable ‘if they accelerate their work on prevention and care redesign’ via implementation of the NHS Five Year Forward View. Providers should be engaged in the local Health and Wellbeing Board and ensure they are aware of Better Care Fund local developments.

NBT Finance

Figures 96 and 97 show an increase in funding over time with the distribution by source remaining fairly stable.

Figure 96: NBT income over time

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530,000 2010/11 520,000 2011/12 510,000 2012/13 500,000 2013/14 490,000 2014/15 480,000

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Figure 97: NBT income by source over time

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Other 300,000 Education Training and Research Revenue from Patient Care Activities 200,000

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- 2010/11 2011/12 2012/13 2013/14 2014/15

Alongside the impact of tariff changes, the principle movements in clinical income were:

• 2013/14 - Transfers in for urology and breast (£5m) and out for head and neck (£9m)

• 2013/14 – Growth in T&O of £3m, renal £3m and the impact of tariff change including the introduction of unbundling £5m and maternity pathway £3m. • 2014/15 – movement in the year the result of the transfer out of South Gloucestershire Community services (£15m), specialist paediatrics (£14m) and vascular and breast transfers in (£5m).

The main movements in other income were due to:

• Transitional funding from NHS South West to support the new hospital scheme, covering project costs and accelerated depreciation costs (2014/14 transitional funding of £17m and non-recurrent support of £14m, 2014/15 – support for PFI of £5m); • Research grants from NIHR and research delivery funding from the research network. • Reduction in education and training income as a result of the national rebasing exercise.

Figure 98: NBT Income by category

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£200,000

2010/11 £150,000 2011/12 2012/13 £100,000 2013/14 2014/15 £50,000

£0 Inpatients Outpatients Other

Figure 98 details the income by activity type and shows fairly stable income for inpatients and outpatients with a reduction in 2014/15 reflecting a number of assumptions including the Trust move and vascular service centralisation. The ‘other’ activity type includes: • High cost drugs and devices • Critical Care activity • Block contracts (including CCHP) • Renal Dialysis • Rehab beds days • A&E attendances.

Figure 99: NBT income over time – split by commissioner

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£0 South Bristol North Somerset NHS E Specialist Other Gloucestershire Commissioning

The commissioning landscape has changed during the 5 years view outlined in figure 99 above. The 2012 Health Act introduced the current commissioning arrangements. From April 2013 activity commissioned by specialised services was redefined and removed from local commissioning arrangements (provided by Regional specialist commissioners funded by PCTS) and directly commissioned by NHS England. The year on year comparison of income by commissioner reflects this change.

Table 14 below shows income for the highest 10 Specialties for the years 2012/13 to 2014/15. A reduction in income over the three years can be seen in trauma and orthopaedics, neurosurgery, midwife episodes (over 2 years) and plastic surgery. Increases in income are seen in community medicine, general surgery, general medicine (2 years’ worth of data), urology and A&E (2 years’ worth of data).

Table 14: Income by specialty

Specialty 2014/15 2013/14 2012/13

110 - Trauma & 46,532,149 Orthopaedics 39,491,039 49,422,057

361 - Nephrology 29,253,295 32,036,817 29,173,474

900 - Community 24,040,855 24,310,892 Medicine 25,632,402

100 - General Surgery 25,207,182 24,312,986 22,947,589

300 - General Medicine 23,982,426 11,512,781

150 - Neurosurgery 23,451,676 32,409,735 31,327,969

101 - Urology 16,055,304 16,115,597 12,295,584

560 - Midwife Episode 15,797,846 16,180,196

950 - Direct Access 15,595,795 15,229,850 16,125,237

160 - Plastic Surgery 13,893,747 19,278,510 19,681,114

180 - Accident & 13,277,682 12,180,909 Emergency

Trust costs

A recent report to the Trust’s Finance and Performance Committee (January 2016) provided the final position for the 2014/15 reference costs for the Trust. Reference Costs use casemix adjusted measures for comparing every Trust’s costs to the national average. For inpatients, day cases and outpatient procedures the casemix measure is Healthcare Resource Groups (HRGs). Outpatient attendances are classified according to their Treatment Function Code (TFC) which is similar to specialty. Reference Costs are calculated on a full cost absorption basis including indirect costs and overheads, net of training and research income, non- patient care income and profits from private patient activity. The Trust received an overall score of 113, which compares to 104 for 2013/14 for the Market Forces Factor (MFF) adjusted position at episode level. This means that the Trust is 13% above national average costs. The level of expenditure increased during 2014/15 due to the hospital move – both the PFI costs spread across specialties using the Brunel building and lower activity levels.

Table 15: Trust quantum

National NBT Reference Reference average Point of Delivery Quantum Costs Index Costs Index Quantum £m 2014/15 2013/14 £m A&E 14.67 14.12 104 105 Contacts 20.22 10.64 190 142 Critical Care bedday 32.82 29.07 113 107 Daycase 36.59 30.55 120 99 Dialysis 12.37 13.98 88 82 Direct Access Pathology 7.41 7.14 104 107 Direct Access Radiology 7.99 6.38 125 116 Drug 23.67 26.09 91 152 Elective IP 65.13 55.40 118 104 Non-Elective IP 146.63 130.11 113 98 Other 8.43 7.93 106 106 Outpatients 77.03 68.69 112 100 Rehab bedday 16.39 18.55 88 98 Total 469.35 418.66 112 103

Table 15 above shows the Trust’s quantum (cost) in comparison to the expected quantum for that level of activity based on the national average unit cost. Further details on reference costs at directorate and specialty level are shown in section 3 on activity data.

The table below (table 16) indicates the specialities which if moved towards achieving the national average would impact notably on reducing the Trust’s overall reference cost index. These include T&O, general surgery, neurosurgery and geriatric medicine. Whilst these need to be key areas to consider when looking at opportunities, it should also be noted that data quality issues may also be driving these and further analysis is required to understand both how the reference cost index could be brought in-line with the national average and also how activity is reported and costed within other Trusts.

Table 16: Reference cost data

National Reduction to NBT Reference average Trust RCI if Directorate Reporting Specialty Quantum Costs Index Quantum Opportunity Opportunity £m 2014/15 £m £m achieved

Musculoskeletal Trauma & Orthopaedics 54.96 44.09 10.87 125 2.60

Surgery General Surgery 34.26 28.94 5.32 118 1.27

Neurosciences Neurosurgery 26.22 22.06 4.16 119 0.99

Medicine Geriatric Medicine 13.94 10.01 3.94 139 0.94

Surgery Urology 20.70 17.54 3.15 118 0.75

Medicine General Medicine 24.17 21.66 2.51 112 0.60

Core Clinical Radiology 14.24 12.03 2.21 118 0.53

Neurosciences Neurology 8.42 6.49 1.94 130 0.46

Women & Children Gynaecology 11.81 9.89 1.92 119 0.46

Medicine Gastroenterology 8.13 6.38 1.74 127 0.42

Medicine Accident & Emergency 3.82 2.28 1.54 168 0.37

Neurosciences Stroke Medicine 4.49 3.01 1.48 149 0.35

Core Clinical Physiotherapy 3.51 2.08 1.42 168 0.34 Surgery Plastic Surgery 15.78 14.45 1.33 109 0.32

Figure 100: Commissioner split of funding

Figure 100 shows a summary the activity levels by admission type commissioned at local Trusts for South Gloucestershire and Bristol CCGs.

Figure 101 NBT expenditure over time:

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500,000 Other Impairments and Reversals 400,000 Depreciation and Amortisation

300,000 Employee Benefits Supplies and Services - Clinical 200,000

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- 2010/11 2011/12 2012/13 2013/14 2014/15

In line with acute trust norms, pay costs equate to circa 64% of the value of the Trust’s income. Pay costs per whole time equivalent have risen in line with pay awards and incremental drift.

In 2011/12 the Trust took on the management of the NHS South Gloucestershire Community provider services which resulted in the increase in staffing numbers noted in that year. There have also been changes in staff numbers as a result of services transfers.

Additional staff were appointed in 2013/14 on a fixed term basis in order to facilitate the move into the new hospital. This resulted in an increase in staff numbers during this period.

Figure 102: NBT projected financial position

Statement of Comprehensive Income 14/15 15/16 16/17 17/18 18/19 19/20 20/21 £m £m £m £m £m £m £m Income Clinical Revenue 431.7 465.9 438.4 434.8 429.9 424.9 419.9 Education, Research and Development 31.3 35.5 35.7 35.8 35.9 36.0 36.2 Other Income 91.4 57.6 51.3 52.2 52.9 53.6 54.3 Total Revenue 554.4 559.0 525.3 522.8 518.7 514.5 510.4

Operating Expenses Employee benefit Expenses (346.1) (350.4) (322.4) (307.4) (299.1) (294.2) (289.5) Other Expenditure (177.9) (175.8) (157.3) (155.0) (153.0) (152.7) (151.9)

Surplus/(Deficit) from operations 30.3 32.8 45.6 60.4 66.7 67.6 69.0 Adjustment for Donated asset income 0 -0.3 -0.3 -0.55 -0.55 -0.55 -0.55 EBITDA 30.3 32.5 45.3 59.8 66.1 67.1 68.5

Non-Operating Expenses Depreciation and Impairment (24.8) (38.1) (22.1) (22.7) (23.2) (23.7) (23.7) Interest Expense (32.8) (33.8) (34.9) (34.8) (34.8) (34.5) (35.1) PDC Dividend Expense (0.1) (0.8) (0.4) (0.2) (0.6) (0.8) (1.1)

Net Surplus / (Deficit) (27.4) (40.0) (11.9) 2.7 8.2 8.6 9.1 Adjustment for Impairments 7.5 15.7 0.0 0.0 0.0 0.0 0 Adjustment for Donated Income (0.3) (0.3) (0.3) (0.6) (0.6) (0.6) (0.6) Technical Adjustment 0.4 Net Surplus / (Deficit) after (19.7) (24.5) (12.2) 2.1 7.6 8.1 8.6 Impairments

The Long Term Financial Model (LTFM) has a base year of 2015/16 and forecasts financial performance up to and including 2020/21 based on the following key assumptions.

• Elective activity growth at 1% year 1 (0.2% following years), excluding Orthopaedics at 5% year 1 (2% following years). • Non elective is offset by QIPP • No explicit impact of Seven Day Service assumed with funding or additional costs • Tariff changes in 2016/17 onwards are overall revenue neutral to the Trust (excluding tariff deflator / inflator). • Post 2015/16 all increases in income are assumed to have 100% marginal cost either to support the savings programme or to fund outsourced activity. • The reduction in backlog income in 2016/17 (£2.5m) has an equal effect on expenditure. • Ceasing to provide CCHP has a favourable real financial impact of £0.9m per year.

CCG Finances

At the end of 2014/15, South Gloucestershire CCG reported that it has delivered its financial plan agreed with NHS England of a £6.671m overspend against its resource allocation of £265.988m. The overspend is 2.5% of the allocation and means that the CCG has not met its duty to break-even on its commissioning budget for revenue. The consequence of this financial result is that the CCG will incur a non-recurring allocation reduction in 2015/16 in order to repay the deficit.

Bristol CCG performed well financially in 2014-15, declaring a surplus of £6.4 million for the financial year.

2.3 Performance

November Integrated Performance Report executive summary

Access – The Trust failed the 4 hour A&E, October’s performance at 86.1% against a target of 95%. The Urgent Care Recovery Plan (UCRP) and its four work streams detail the actions by both the Trust and its partners and will be reviewed for a new improvement trajectory in November. The number of patients with Length of Stay over 14 days is on an upward trend in line with the increased delayed transfer of care patients which during October reached 5.9%. The Trust exceeded its trajectory for 2015/16 RTT incomplete performance 3860 vs. a target of 4408. Diagnostics performance was met in October at 99.4%

The final position of Cancer targets in September showed the Trust had delivered on 5 of the 8 Cancer waiting targets. The ‘unvalidated’ position currently has the Trust passing 5 of the 8 key targets in October.

Safety - Pressure ulcer incidence has improved in month, with no grade 4 pressure ulcers this year and no grade 3’s for 2 consecutive months. The Trust has reported 13 mixed sex breaches in interventional radiology the first in this financial year. Safe staffing continues to be achieved with no wards triggering the early warning trigger tool.

Patient Experience - Overdue complaints have risen from 14 to 32 . The Heads of Nursing in each area are addressing this to get back on track for the end of November . Comments on NHS Choices are now predominately compliments including positive comments about the emergency zone

Workforce - 195 wte new entrants started during October against a trajectory of 144 wte. A number of actions are being taken to control pay expenditure. Overall compliance in statutory and mandatory training has dropped below the 85% compliance level.

Finance - For the year to date the Trust is £11.9m adverse to plan, the primary drivers for the adverse to plan were lower than planned income of £6.5m and together with pay overspends of £5m coupled with a small non-pay overspend of £0.5m.

There is an implementation of Directorate and Trust wide financial recovery plans to reduce agency expenditure and increase elective activity.

Figure 103: Key performance trends

Figure 104: Numbers of patients in beds – medically fit for discharge / awaiting rehabilitation

Hospital Standardised Mortality Ratio (HSMR) and Standardised Hospital Mortality Indicator (SHMI)

NBT consistently measures below the national average of 100 on both measures of mortality.

Figure 105: Mortality Ratio

The Trust has worked on improving patient safety for many years having been involved in wave 2 of the national Safer Patients Initiative and members of our staff have taken a leadership role in the subsequent Safer Patients South West Programme and in the West of England Academic Health Science Network patient safety collaborative. North Bristol NHS Trust was one of the first 12 ‘Pathfinder’ organisations who signed up to the campaign and its pledges. The campaign is designed to help realise the ambition of making the NHS the safest healthcare system in the world by creating a system devoted to continuous learning and improvement.

Table 17: Care Quality Commission – result of most recent inspection

Safe Effective Caring Responsive Well-led Overall

Urgent and Requires Requires emergency Inadequate Good Inadequate Inadequate improvement improvement services Requires Requires Requires Requires Requires Medical care Good improvement improvement improvement improvement improvement Requires Requires Requires Requires Requires Surgery Good improvement improvement improvement improvement improvement Requires Requires Requires Critical care Good Good Good improvement improvement improvement Maternity Requires Requires Requires Good Good Good and gynaecology improvement improvement improvement Services for children and Good Good Good Good Good Good young people Requires Requires Requires Requires Requires End of life care Good improvement improvement improvement improvement improvement Outpatients and Requires Requires Requires diagnostic Not rated Good Good improvement improvement improvement imaging Requires Requires Requires Requires Requires Overall Good improvement improvement improvement improvement improvement

2.4 Quality

The Lord Darzi review, High Quality Care for All (Department of Health, 2008) refocused attention on the importance of high quality and safe care within the NHS. He defined Quality care as clinically effective, personal and safe, with patients treated with compassion, dignity and respect. The NHS Outcomes Framework developed in December 2010 and updated every year since, sets out the high level aims of the NHS for improving patient outcomes. These are the underpinning principles for the work we do in North Bristol NHS Trust.

The vision for delivering high quality and safe care for all was explicitly stated in the NHS Constitution (2011). The Constitution sets out the rights patients can expect from the NHS including quality and safety of care, confidentiality, information and a right to complain if things go wrong. In a complex environment care that is standardised as much as possible is more reliable and therefore safer and more likely to provide patients with the outcome and experience they expect.

Everyone Counts: Planning for patients 2013/14 committed the NHS to move towards routine services being available seven days a week. We must ensure that patients receive the same level of support no matter when they are admitted into our care. The Royal College of Physicians of London (Future Hospital Commission) commented that “Acutely ill medical patients in hospital should have the same access to medical care on the weekend as on a week day. Services should be organised so that clinical staff and diagnostic and support services are readily available on a 7-day basis. The level of care available in hospitals must

reflect a patient’s severity of illness. In order to meet the increasingly complex needs of patients – including those who have dementia or are frail – there will be more beds with access to higher intensity care, including nursing numbers that match patient requirements.” As a Trust we need to be clear about our willingness to meet this need.

MacMillan looked at how staff were caring for patients and found that there are a number of barriers that affect the ability of NHS staff to provide a good experience of care. The MacMillan work found that there are a number of barriers which impact on a member of staff’s ability to provide a good experience of care to patients. These include:

• a lack of on-going learning and development; • poor health and wellbeing; • not enough time with patients; • poor communication and support at management level, team level and throughout the wider organisation; • not being empowered and being unable to raise concerns; and • discrimination, harassment and bullying.

The MacMillan findings match the results of the latest NHS Staff Survey. For example, only 48% of NHS staff received training on how to deliver a good experience of care to patients in the past year.

On a number of metrics, the Trust performs very well but our most recent CQC inspection (November 2014) shows some clear areas for improvement. The report from the CQC rated the Trust as “requires improvement” with a specific requirement to make immediate changes in the Emergency Department where overcrowding was felt to be impacting on the quality of care given. This was despite every service being rated as being “good” in the context of caring and Trust staff being described by the CQC as being “committed and passionate.”

The Trust has a good record on patient mortality and both internal and external assessments of its performance indicate that it is consistently performing at or better than the national expected levels on a range of measures that are used to monitor and assess mortality.

Our infection control results are improving. In 2014/15 there were no cases of MRSA blood stream infection recorded within the Trust and 2014/15 has seen a significant improvement in the reduction of the numbers of patients recorded as having Clostridium difficile (C.diff). There has been a continued year on year reduction in C.diff patients since 2010/11.

We know that patient experience is variable between services and between different episodes of care. We are yet to reach high reliability across all of our quality of care measures.

The NHS Services, Seven Days a Week Forum recommended that by 2016/17 the NHS should adopt 10 evidence-based clinical standards to end current variations in outcomes for patients admitted to our hospitals at the weekend. We have assessed our current ability to offer 7 day services against the NHS England clinical standards (see table 18).

Table 18: clinical standards

STANDARD YES/NO REASONS FOR NON-COMPLIANCE Patient Experience YES Time to first consultant review NO Not compliant across all specialties and the strict requirement of a 14 hr consultant standard for all emergency admissions would require significant investment MDT review NO Trust fails to meet the standard based on therapist support for an MDT assessment Shift Handovers YES Diagnostics YES Interventional services YES Mental Health NO The service operates for 10 hours per day over 7 days. Plans are in place to recruit to allow increase in provision to 13 hours per day. On-going review NO Non-compliant for twice daily consultant review of all patients on our assessment units. Transfer to community, primary NO Support services (community health, social and social care care) available but variable response and effectiveness. Quality improvement YES

The standards shown in “blue” are the high quality clinical standards and at this point in time, we can meet two of the four requirements.

Reducing Harm from Infection

In 2014/15 there were no cases of Methicillin Resistant Staphylococcus Aureus (MRSA) blood stream infection recorded within the Trust, compared to 1 case last year. We have also seen a significant improvement in the reduction of the numbers of patients recorded as having Clostridium difficile (C.diff) and the Trust has met the national set target in 2014/15. This year’s final figure shows a continued year on year reduction in C.diff patients since 2010/11, as reflected in figure 106.

Figure 106: HCAI

C-Difficile Infections 12 10 8 6 4 2 0

MRSA Infections 1.2 1 0.8 0.6 0.4 0.2 0

Hand Hygiene Compliance 98.0% 96.0% 94.0% 92.0% 90.0% 88.0% 86.0% Jul-14 Jul-15 Jan-15 Sep-14 Sep-15 Nov-14 Mar-15 May-14 May-15

The Trust has reduced the numbers of patients recorded as having Clostridium difficile (C.diff) consistently since 2010/11 and MRSA rates are exceptionally low.

Figure 107: HCAI rates

Serious Incidents NBT is at the lower end of reporting figures. The Trust is slightly above the national average in terms of Moderate and Severe incidents. The Trust reported 87 serious incidents in 2014/15 compared to 54 in the previous year (see figure 108).

Figure 108: Serious incidents

Incidents reported by degree of harm for large acute organisations, 01 April 2014 to 30 September 2014

There were three never events reported in 2014/15.

iCARE

The iCARE programme was launched in September 2014 in order to build upon our strengths in caring for patients and supporting for colleagues, by recognising and spreading best practice.

iCARE stands for: I take responsibility for; Communication that’s effective Attitude that’s positive Respect for patients, carers and colleagues Environment that’s conducive to care. Approximately 4,500 staff have attended an iCARE session including all new staff at induction and bespoke sessions for staff working in various environments, including receptionists in the Emergency Department, the Sterile Services Department, Facilities, the IT Service Desk and Switchboard, Volunteer Services, and the Acute Assessment Unit. It has enabled people who work directly with patients to reflect on how they work together to provide an environment conducive to care, and enabled staff who work in support areas to see how their work enables others to provide high quality care.

Pressure Ulcer Care Our targeted work on Grade 3 and 4 Pressure ulcers has resulted in reduction in numbers of patients affected. We have identified themes across acute and community organisations which are being addressed through collaboration of BNSGG Tissue Viability teams and there is a community-wide thematic review of pressure area care currently in progress.

Falls We have had a longstanding focus on falls reduction – reflected in pre-move levels. There was a spike in overall & serious falls post move (May 14) and an increase in overall falls in winter 2015. We have taken a number of actions to address this including: • Lead Falls Nurse (in post from September) has delivered face to face training for 179 nursing staff in last 5 weeks • New equipment being purchased to improve care for highest risk patients (delirium and dementia)

Figure 109: pressure ulcers Grade 2 + Pressure ulcers Per 10000 Bed Days 14 12 10 8 6 4 2 0

Grade 3 and 4 Pressure ulcers 3.5 3 2.5 2 1.5 1 0.5 0

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Figure 110: falls data Falls Per 1000 Bed Days 10.0 8.0 6.0 4.0 2.0 0.0

Falls report as Serious Incidents (by reported date) 10 8 6 4 2 0

However there is more to do. We know that patient experience is variable between services and between different episodes of care. We are yet to reach high reliability across all of our quality of care measures.

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2.5 Patient feedback

The Trust’s patient Experience team reports to the Quality and Risk Management Committee. Improvement themes both in terms of process and patient views include the following:

• Overall intelligence gathering needs improvement - gain a more sophisticated understanding of patient experience beyond purely Friends and Family test and National Inpatient Survey data. • Friends and Family Test – improve participation, analysis and learning • Complaints – improve timeliness and quality of responses • Carers – improve their involvement in discharge planning and ongoing involvement in decisions about the patient they are caring for • Consent / shared decision-making – testing the effectiveness of patients’ understanding of their treatment options • Patient Information – requires improvement • Patient Voice– needs better structuring to pull together the pockets of good practice around the trust more coherently • Complaints themes have recently centred around delays and cancellations for elective procedures, difficulties getting through to wards or to administrators to query clinic or follow up bookings, transport and parking.

Friends and Family Test (patient responses)

The most recent results from the August 2015 test, show an improving trend although the response rate is still low (c.15%).

Figure 111: Friends and Family Test (patients) – response to Question 1: ‘How likely or unlikely are you to recommend North Bristol NHS Trust to friends/family if they needed care or treatment?’ 80.0 69.0 71.0 70.0 66.0 61.0 60.0 60.0 50.0 40.0 % Extremely Likely/Likely 30.0 % Extremely unlikley/unlikely 19.0 20.0 16.0 14.0 9.0 8.0 10.0 0.0 Q1 2014 Q2 2014 Q4 2014 Q1 2015 Q2 2015

2.6 Staff feedback

Results from the staff survey show that we can do a lot to improve how our staff feel about working at NBT. The 2014 staff attitude survey was particularly disappointing with the NBT results being in the worst 20% for 10 out of the 20 questions. The survey was taken just after the Move into Brunel and as such reflected a stressful time at the Trust but still shows that there is tremendous scope to improve how staff feel. The one question where our staff were

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positive was about the % of staff receiving job-relevant training, learning or development in last 12 months.

Figure 117: Trust performance staff feedback

Appendix 1 : Summarising the Trust's 2014 performance compared to national benchmarks and the Trust position in 2013 Position in Position in National respect of respect of NBT NBT Average other Acute other Acute Key Factor 2013 2014 score 2014 Trusts 2013 Trusts 2014 note 1 - Scores in italics are better when lower note 2 - single figures are %, decimal figures are scored between 1 and 5

Staff Pledge 1 - to provide all staff with clear roles and responsibilities and rewarding jobs % of staff feeling satisfied w ith the quality of w ork and patient care Worse than KF1 they are able to deliver 77 66 77 average Worst 20% Better than KF2 % of staff agreeing that their role makes a difference to patients 91 85 91 average Worst 20% Worse than KF3 Work pressure felt by staff 3.11 3.25 3.07 average Worst 20%

KF4 Effective team w orking 3.68 3.66 3.74 Worst 20% Worst 20%

KF5 % of staff working extra hours 70 78 71 Average Worst 20%

Staff Pledge 2 - to provide all staff with personal development, access to appropriate training for their jobs and line management support to succeed % of staff receiving job-relevant training, learning or development in last Better than Better than KF6 12 mths 82 82 81 average average Worse than KF7 % of staff appraised in last 12 mths 92 80 85 Best 20% average Worse than KF8 % of staff having w ell structured appraisals in last 12 mths 34 27 38 average Worst 20%

KF9 Support from immediate managers 3.65 3.52 3.65 Average Worst 20%

Staff Pledge 3 - to provide support and opportunities for staff to maintain their health, well-being and safety Worse than KF10 % of staff receiving health and safety training in last 12 mths 70 61 77 average Worst 20% Worse than KF11 % of staff suffering work-related stress in last 12 mths 38 51 37 average Worst 20% % of staff witnessing potentially harmful errors, near misses or KF12 incidents in last mth 38 46 34 Worst 20% Worst 20% % of staff reporting errors, near misses or incidents w itnessed in the KF13 last mth 93 80 90 Best 20% Worst 20%

KF14 Fairness and effectiveness of incident reporting procedures 3.5 3.39 3.54 Average Worst 20% % agreeing that they w ould feel secure raising concerns about unsafe KF15 clinical practice - 59 67 - Worst 20% % of staff experiencing physical violence from patients, relatives or Worse than Worse than KF16 the public in last 12 mths 16 17 14 average average Better than KF17 % of staff experiencing physical violence from staff in last 12 mths 2 3 3 average Average % of staff experiencing harassment, bullying or abuse from patients, KF18 relatives or the public in last 12 mths 30 32 29 Average Worst 20% % of staff experiencing harassment, bullying or abuse from staff in Better than Worse than KF19 last 12 mths 23 26 23 average average % of staff feeling pressure in last 3 mths to attend work when feeling KF20 unwell 28 30 26 Average Worst 20% Staff Pledge 4 - to engage staff in decisions that affect them and the serv ices they prov ide, indiv idually , through representativ e organisations, and local partnership w orking arrangements. All staff w ill be empow ered to put forw ard w ay s to deliv er safer serv ices for patients and their families. % of staff reporting good communication betw een senior management Worse than KF21 and staff 25 24 30 average Worst 20% Worse than KF22 % of staff able to contribute tow ards improvements at w ork 71 68 68 average Average

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Staff Satisfaction Better than KF23 Staff job satisfaction 3.67 3.49 3.6 average Worst 20% Staff recommendation of the trust as a place to w ork or receive Worse than KF24 treatment 3.56 3.29 3.67 average Worst 20%

KF25 Staff motivation at w ork 3.88 3.61 3.86 Average Worst 20%

Equality and Diversity

KF26 % of staff having equality and diversity training in last 12 mths 39 34 63 Worst 20% Worst 20% % of staff believing the trust provides equal opportunities for career Worse than KF27 progression or promotion 89 86 87 Average average Better than Worse than KF28 % of staff experiencing discrimination at work in last 12 mths 10 12 11 average average

Patient Experience Measures agreeing feedback from patients/service users is used to make Worse than KF29 informed decisions in their directorate/department - 27 56 - average

2013 2014 Best 20% 2 - Better than Improved average 7 1 No Change /Ne w 3 Average 7 2 Worse than W orse 26 average 8 6 Worst 20% 4 20

Staff Friends and Family Test (staff responses)

Figure 118: Friends and Family Test (patients) – response to Question ‘How likely or unlikely are you to recommend North Bristol NHS Trust to friends and family as a place to work?’

60.0

48.0 50.0 46.0 47.0 41.0 39.0 40.0 38.0 35.0 31.0 30.0 28.0 27.0 % Extremely Likely/Likely % Extremely unlikley/unlikely 20.0

10.0

0.0 Q1 2014 Q2 2014 Q4 2014 Q1 2015 Q2 2015

Our partnership with Job Centre Plus enables us to support young people not in education or training (NEETs) in traineeships and often into employment with NBT and into apprenticeship programmes. Our Apprenticeship Centre is of a unique pedigree as an employer based education provider with our own Skills Funding Agency apprenticeship contract. We see our apprenticeship programme as the start for many people who will go

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onto fruitful health care careers at all levels, with NBT, and the wider health and social care economy.

Feedback from some of the Senior Leadership events has identified a requirement from staff to receive more training, not just in clinical areas but in areas such as commercial skills and leadership training. It is our intention to make NBT an organisation that people wish to work for, not least because of the on-going opportunities we provide for staff to develop and improve their credentials.

We also see a need to develop strong teams which can work autonomously and enable talent to be recognised and good leadership supported and rewarded and continued focus on succession planning and appropriate skill mix.

2.7 Workforce

An analysis of the workforce profile shows an increasing dependence upon temporary staff across most staffing groups. This is particularly apparent in the healthcare assistants and other support staff category.

Figure 117: Workforce profile

1,800

1,600

1,400

1,200 Healthcare assistants and 1,000 other support staff - other

800 Healthcare assistants and other support staff - 600 permanent

400

200

- 2010/11 2011/12 2012/13 2013/14 2014/15

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Average Staff Numbers 2010/11 2011/12 2012/13 2013/14 2014/15 Medical and dental - permanent 799 800 819 829 836 Medical and dental - other 23 17 13 7 17 Administration and estates - permanent 1,503 1,555 1,547 1,590 1,487 Administration and estates - other 82 131 128 132 133 Healthcare assistants and other support staff - permanent 1,266 1,225 1,178 1,118 1,159 Healthcare assistants and other support staff - other 166 273 416 526 471 Nursing, midwifery and health visiting staff - permanent 2,216 2,280 2,342 2,404 2,263 Nursing, midwifery and health visiting staff - other 192 151 165 209 257 Scientific, therapeutic and technical staff - permament 1,414 1,527 1,498 1,437 1,350 Scientific, therapeutic and technical staff - other 4 2 10 18 23 TOTAL 7,665 7,961 8,116 8,270 7,996

Figure 118: Age profile of NBT staff and length of employment

Age Profile: 1000.00 900.00 Figure 118 illustrates 800.00 that 14.5% of the 700.00 workforce are 56 600.00 years of age and 500.00 older. 400.00 The age profile of the 300.00 workforce who are 56 200.00 and older is of 100.00 particular concern in 0.00 Estates (23%) and 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71 + Grand Total Admin and Clerical (22%).

Figure 119: Length of employment:

35.0%

30.0%

25.0%

20.0%

15.0%

10.0%

5.0%

0.0% 0-6months 7-11 months 1-2 years 3-4 years 5-10 years over 10 years Grand Total

This illustrates that almost 20% of the workforce leave the Trust within the first year and over 37% leave within the first two years.

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Figure 120: Workforce turnover

Figure 121: starters and leavers

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Section 3: What is expected of us?

Key messages:

Relevance to strategic aims:

- Play our part in a successful healthcare system

3.1 NHS Five Year Forward View

The NHS Five Year Forward View (NHS England, 2014) sets out a number of recommendations and describes changes that need to happen within the NHS. Relevant to Acute Trusts specifically include the following: - Patients should gain far greater control of their own care for example clinicians and others should work to enable self-management - The NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care - Across the NHS, urgent and emergency care services will be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services - A further new option will be the integrated hospital and primary careprovider -Primary and Acute Care Systems - combining for the first time general practice and hospital services.

The 2016/17 NHS Planning Guidance (NHS England, 2015) sets out requirements for local health and care systems to enable and expedite delivery of the Five Year Forward View. Relevant requirements for Acute Trusts include the development of local Sustainability and Transformation Plans, and achievement of targets including A&E waits, referral to treatment and cancer waiting time targets.

3.2 Local CCG Priorities

Across England, local health and social care systems are working on plans for transforming their services in response to the challenges posed by people living longer with poor health, workforce shortages and growing financial shortfalls in the absence of change. Better Care Fund and health and social care integration discussions are also relevant local system priorities.

As part of the planning process, all NHS organisations are asked to produce two separate but interconnected plans:

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1.A local health and care system ‘Sustainability and Transformation Plan’, which will cover the period October 2016 to March 2021; and

2.A plan by organisation for 2016/17. This will need to reflect the emerging Sustainability and Transformation Plan.

The nine ‘must dos’ for 2016-17 include:

1. Produce a sustainability and transformation plan for the health economy.

2. Return to “aggregate financial balance” with secondary care providers delivering savings through the Lord Carter productivity programme and caps on agency spending. CCGs will be expected to save money through reducing variation and implementing the Right Care programme in every area.

3. Develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues.

4. Achieve waiting time targets for A&E patients and ambulance response times.

5. Improve and maintain performance against the 18 week RTT target.

6. Deliver the 62 day cancer waiting time target, including the two week referral and 31 day treatment targets. The guidance also calls for progress in one year survival rates by increasing the proportion of cancers diagnosed early.

7. Achieve and maintain new mental health waiting time targets which include more than 50 per cent of people experiencing a first episode of psychosis being treated within two weeks of referral and 75 per cent of people with common mental health conditions being referred to talking therapies within six weeks of referral, with 95 per cent treated within 18 weeks. Areas will also need to diagnose two thirds of their estimated population that has dementia.

8. Improve care for people with learning disabilities including improved community services and reducing inpatient facilities.

9. Providers will be required to publish avoidable mortality rates annually.

A joint vision for health and social care in Bristol, North Somerset and South Gloucestershire has been produced. The document describes a commitment by leaders of health and social care services in Bristol, North Somerset and South Gloucestershire to a collective effort to transform services and improve outcomes for the populations served. It sets out a vision in a series of themes, focused on improving people’s experience of health and social care, and developing a sustainable health and social care system that makes better use of existing capacity and resources via the production of Sustainability and Transformation plans.

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Section 4: How do we see ourselves?

Key messages:

- Common themes relating to demand, productivity, capacity,

workforce, quality and finance exist within all directorate plans for future priorities and service requirements. Common themes include the desire to develop specialist work, the need to work with stakeholders to improve patient flow and ensure patients receive the right care in the right place at the right time, and the need to support patients to enable self-management where appropriate - A move to increased cross-directorate planning is also highlighted in directorate plans for the future along with robust workforce

succession plans and a focus on safety, quality, performance and research - Directorates are aware of common cross-cutting clinical themes that should be taken into account when planning for the future such as multi-morbidities, mental health, alcohol harm reduction and inequalities - An analysis of strengths, weaknesses, opportunities and threats by senior leaders within NBT identified a number of priorities including:

o build on our areas of clinical excellence and specialist expertise o develop as a system leader to drive changes to service and pathway design – work proactively

o lead on the research agenda o work with patients to enable self-management where appropriate

o develop our workforce improve our relationship with stakeholders o o improve our information and intelligence function o improve our succession planning identify and remain engaged in plans regarding health and o social care budgets, specialised commissioning budget changes o engage in whole healthcare system planning regarding the NHS Five Year Forward View to manage issues such as increasing demand, public expectation and competition ensure cross-directorate planning occurs where appropriate. o

Relevance to strategic aims:

- The key messages are relevant to all eight strategic aims.

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4.1 Directorate level input

The following summaries at Directorate level focus on key priorities going forward in relation to demand, productivity, capacity, workforce, quality, finance, and impact on other directorates. The information is based on Directorate presentations at a recent Trust-wide ‘Present and Challenge’ session and discussions with Clinical Directors during January 2016.

Renal

At a national level the national organ donation strategy aims to double the number of transplants by 2020. If this ambition is achieved renal services will see a reduction in dialysis and an increase in surgical and theatre capacity being required. It should be noted that going forward the affordability of dialysis within NBT will come into question due to factors such as the cost of consumables and market factors including international dialysis delivery units (often sub-contracted by the NHS). The home dialysis rates at NBT are above average (approximately 16% dialysed at home) yet it should be noted that location (rural vs urban) and age of patients impacts upon the decision to be dialysed at home. NBT is nationally within the top 5 pre-emptive transplant rates and top 10 living donor transplant rates.

Regionally NBT offers a service for kidney disease and transplants (to a population of approximately 1.4 million). Key priorities to tackle going forward include a need to facilitate timely social care support for those patients outside of BNSSG in order to enable discharge and reduce length of stay to the benefit of the individual and the Trust. This is also relevant to those individuals requiring nursing home beds.

Locally no real challenges exist. Revised processes in place following the hospital move have improved patient flow and reduced length of stay within renal services.

Overall key priorities going forward include improved engagement with social care and increasing super-specialty activity. Overall funding has reduced over the last ten years yet RTTs are always met therefore any potential shift of activity into the community or primary care would need to clearly identify the benefit to NBT. Recent developments have included the establishment of community based clinics and community nurse provision is in place to control the symptoms of elderly patients choosing not to receive dialysis. This also includes liaison with end of life care provision when required. Given the ageing population this may be an area of increased activity in the future. Opportunities to prevent acute kidney injury via education and prompts to GPs regarding ‘sick day’ rules and ACE inhibitors could be progressed in the future.

Other priorities going forward include development of the Bath Dialysis Unit (due to open 2017/18) and review of the centralised outpatient function. There are no plans for any significant changes to service delivery and the Directorate intends to remain within the current bed base. Capacity issues do however include theatre utilisation and workforce issues (ageing workforce and Specialty Registrar gaps). For renal services priorities identified in relation to quality include the South Bristol Dialysis Unit, Vascular Access, IT (proton replacement), transplant surgeon cover and improvement against inpatient quality markers. For outpatients priorities to address quality issues include space utilisation review, security, EDMA and booking office relocation. Extensive links with other Directorates have been identified to support ongoing service delivery such as theatre planning and outpatient activity assumptions.

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Neurosciences

Overall key priorities for the Directorate going forward are as follows:

- Recover financial stability and performance against key targets (referral to treatment) - Improve data and information systems - Design services and staffing capacity to reflect changing case mix for example elderly complex patients; increased co-morbidities - Ensure internal processes are effective for example administrative process and then work on promoting notably the neurosciences element – co-ordinate research eg within neurosurgery. - Stroke is a potential area of growth and risk. Work required reviewing geographical cover of service provision eg stroke at weekends. Also work developing cross- directorate (eg care of the elderly/stroke posts). - Continue good academic links (eg clinical lecturer posts). - Improve links with the community eg to reduce length of stay. - Develop systems to improve local monitoring of outcomes (for example via data clerks). - Review links with therapist teams for example with the good work of the Speech and Language Therapy research unit.

Neurosurgery and epilepsy demand is problematic - current focus is on recovery of the 52 week referral to treatment target for neurosurgery and epilepsy which during 2016/17 remains reliant on independent sector capacity. Theatre capacity issues exist for neurosurgery.

Demand for neurology long-term follow-ups is increasing and DNA rates are high. Improvements in efficiencies required – support is sought from central outpatients and IT. Consideration of approaches to reduce length of stay and bed base is underway, for example via BIRU expansion. Capacity issues exist in relation to 7-day therapy input for stroke.

Neuropsychiatry demand increasing due to revised pain management referral pathways. DNA rates are high as is length of stay and bed utilisation is poor. Clarification of service definition required.

Proposals for workforce development include reducing overall nursing costs by expanding HCA roles and ensure efficiency maximised by reviewing for example CNS roles; reviewing neurology administrative posts; ensuring succession plans in place for neurophysiology, neuropathology and prosthetics; expand therapy provision for neuropsychiatry and stroke.

Financially neurosciences face challenges due to reliance on the independent sector and rising drug costs. Cash releasing efficiency savings are reliant on bed reductions (Brunel), productivity gains (Rosa Burden) and therapy increases in stroke and neuropsychiatry.

Developments within the Directorate aim to support achievement of quality standards, such as the development of a Directorate sharepoint site for governance.

Links with other Directorates are proposed to support the Directorate going forwards including appropriately skilled neuro theatre terms to support list expansion, waiting list initiatives, improved ITU flow and transition, increased therapy input for stroke and

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neuropsychiatry. Other proposals include improved outpatient environment, joint work with MSK such as joint spinal service network, joint Care of the Elderly / Stroke Physicians with medicine.

Medicine

Acute medicine is a dynamic and advanced element of the medical Directorate. Other advanced specialties include infectious diseases, immunology, chest medicine and gastroenterology. The Directorate will prioritise the development and evolution of services taking into account the needs of the population it serves as a whole working with colleagues at University Hospitals Bristol where appropriate.

Priorities going forward include delivering ED performance targets and RRT targets, delivering a 7 day service, performing financially, improving services for mental health patients and strengthening the clinical governance infrastructure. Other areas of focus include respiratory (eg ILD and difficult asthma), diabetes and endocrine (eg increase use of community services; continue tier 3 service provision), care of the elderly (eg increase liaison support as per vascular model); develop ANP, GPSI, joint posts; links to other services and directorates (eg orthogeriatrics and stroke; tepid clinics), cardiology (eg heart failure service development, cath lab utilisation), gastroenterology (eg CNS telephone consultations), immunology and ID (infection strategy required), mental health liaison (expand team and extend working).

Pathways for frail elderly will also be a priority going forward with a focus on facilitating timely discharge, requiring community support and the ability of patients and carers to self- manage where appropriate.

In relation to quality and performance against national audits, the directorate will prioritise further development of its clinical governance infrastructure (for example revising the RCA process). Accessing timely and robust data via the Trust is required to improve the quality of service delivery and reporting.

Key issues for the directorate going forward include resourcing, recruiting and retaining staff and financial challenges. Extensive links with other directorates is key to attracting and retaining staff, for example with neurosciences for a joint post with stroke; and MSK regarding a proposed move to medicine of orthogeriatrics. The directorate currently has a good cadre of acute physicians and the directorate is likely to expand over the next 1 to 2 years with flexible joint posts being filled.

Also in relation to workforce the Directorate is working with primary care and the Royal College of Physicians to further develop the existing GP Support Team and recruit joint GP/medical physician posts to provide sessional work with a focus on care of the elderly and acute medicine. Cross-cutting clinical these of relevance to the medical directorate include alcohol harm reduction (the alcohol nurse is present at daily ward rounds) and support for patient with mental health issues where improved links with AWP are required.

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Surgery

The vision for the directorate is to be recognised as one of the top 5 centres for surgical care in the country by 2020. Key objectives to achieve this vision include behaving as an autonomous business unit, improving the outcomes and quality for patients, specialty level dialogue with commissioners and partners, enhance the provision of emergency care in surgery.

Recent changes in the ways of working within the directorate have enhanced service provision. Further work is required to ensure the excellent standard of care and outcomes are communicated and recorded. The ambition of the directorate going forward is to ensure pathways are designed which put the patient at the centre and ensure the identity of the Trust as a whole is defined as a unique modern hospital delivering both DGH services and specialist services for a broader geography within a new estate.

As significant specialist service transfers (for example vascular) have recently occurred no other major changes to current service provision are anticipated in the short term. The directorate recognises the potential for future service changes such as working more closely with UHB (for example on emergency surgical take; endocrine surgery etc). The directorate also recognises a potential for decommissioning activity that could be delivered in the community such as low grade diagnostic services.

With regard to quality the directorate works to and achieves national and local audit requirements. Action will be taken where gaps are identified between targets and current service (eg pressure ulcers) and governance structures will be enhanced. The directorate has also identified the need to clarify how patients define quality and develop outcome measures that align to patient-defined priorities.

Capacity issues include a 9% growth in non-elective activity. A lack of theatre space appears for recent emergency theatres data (September 2015) to impact significantly on non-elective activity. General surgery is not achieving RTT (although passing cancer). Plastics and urology are achieving RTT targets. Supported by Emerson’s Green a bed base review suggests a shortfall of 8 beds going forward. An increased demand is being seen for endoscopy. Going forward assumptions include 1% elective and 3% non-elective growth.

Plans to meet non-elective challenges include an increase in the surgical bed base from neurosciences and ambulatory emergency care; develop a consultant of the week model; utilise Emerson’s Green for some hot lists; and enhance ward rounds via surgeon/physician model. Plans to develop elective services include intestinal failure bid, review of dermatology services (Bristol), breast services for North Somerset and potential transfer of thyroid services. Potential future pathway reviews include dermatology, breast care centre and urology.

Workforce challenges going forward include a turnover rate of 10-13%, high clinical admin costs, difficulties recruiting to specific posts eg nurse endoscopist. Plans to overcome this include improving the attractiveness of NBT as an employer (eg introducing Southmead School of Surgery) and developing new roles such as enhanced nurse specialists.

Links with other directorates is seen as key to enabling service level management, robust business intelligence analysis and timely reporting, monitoring and decision-making.

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MSK

Future growth assumptions are 1% for non-elective and 3% for elective (orthopaedics, spinal and rheumatology). Going forward the priority for the spinal service is a reduction of the waiting list and the development of a spinal network. For elective MSK services as a whole a recovery plan exists however this assumes current theatre and bed base capacity and does not address the anticipated increasing future demand. Options have been proposed to address elective capacity in the future and are yet to be fully costed and reviewed.

Regarding workforce challenges and risks include availability specialist skilled staff in theatres, reliance on locum Junior Doctors. Opportunities include a nursing orthopaedic training course, care of the elderly potential links and extended nursing roles. Proposed business cases include a rheumatology workforce plan.

Going forward priorities regarding quality include achievement of VTE assessment and falls assessment; pressure ulcers, 52 week wait target, formalisation of PROMS process (patient reported outcome measures) and timely action and monitoring of complaints. Key challenges regarding finance include reliance on the independent sector, tariff changes and the need to be dependent on using current funding levels to deliver more efficiently.

Links with other directorates are envisioned as being key to future service delivery including with CCS (developing specialist skills in theatres), Surgery (access to T&O bed base), Medicine (care of the elderly and orthogeriatrics), Neurosciences (development of spinal network) and renal and outpatients (increased booking efficiency).

Women & Children

Key priorities going forward are as follows:

- CCHP transfer and legacy issues o Issues relating to this include ensuring robust safeguarding processes in place and paediatric medical input. - Fertility services o Due to reduced demand and recent increase in competitor providers the service is viewed as not financially viable and success rates have reduced. Future service delivery is with the Trust Board for decision. - Maternity, gynaecology and neonatology o Build on exceptional outcomes, increasing growth and develop specialised service activity as a tertiary centre. In order to further develop a national reputation increased capacity is required. o This will require recognition of interventional radiology tariff and activity, increased links with specialised commissioning, improved links with NBT CCC Directorate. o Casemix is becoming more complex as more women with long term conditions and older women become pregnant. Capacity projections should reflect this and also take into account transition (18-25 year olds). o Increasign demand for gynaecology from young and informed population. Issues regarding workforce, emergency take, theatre and bed capacity. - Estates and staff

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o Deliver vision of right woman, right place, right time over three sites which does result in staffing capacity issues and the need to take into account increasing complexity and acuity of births. o Awaiting national maternity services review (due February 2016). - Links with UHB o Ongoing discussions required notably regarding gynae and neonatology although acceptance of two maternity service reviews having already occurred. - Academia o Continuation of strong links with University of Bristol. Joint posts currently in place. Strong focus on intra-partum research. Senior management support for these posts currently via NIHR funding.

Growth is assumed to be 1%. There has been an increase in outpatient referrals and a growing waiting list. There is a potential increase in emergency activity due to the geographical take model. Future priorities include improving theatre efficiency, managing the increasing RTT backlog and a review of the consultant rota.

For gynaecology, additional capacity is proposed via an additional theatre list, outpatient hysteroscopy lists, additional outpatient clinics and gynaecology consultant WTE.

For maternity and obstetrics additional capacity is proposed via maximising use of birth centres, additional elective c-section lists, reducing LOS for induction of labour and postnatal wards and additional sonography time and facilities.

For NICU capacity does not meet demand and proposals for the future include remodelling special care rooms and increasing NICU nurse WTE. There is currently a review of tier 3 NICU services by the South West Neonatal network which may affect NBT if the recommendation is for one service for Bristol. For fertility services an urgent review of the business model is underway due to decreasing demand.

Regarding workforce issues, opportunities to overcome challenges such as an ageing workforce include effective succession planning is required and the development of alternative roles. Financially, delivery against assumed 1% growth is dependent on a number of factors including significant changes to the estate in NICU and maternity and improved flow and reduction in length of stay.

Regarding quality, key priorities going forward include reducing delays for induction of labour and improve 1:1 midwife care in labour.

Support from other directorates going forward is key and includes CCS (to enable additional theatre lists) and estates. Following the CCHP transition to Sirona links will be required regarding legacy services such as speech and language therapy.

Our Breast and Women’s services could be considered to have less connectivity to others that we provide and to some extent, stand apart from the core portfolio. These are both services that deliver exceptional results and have reputations that we are proud of. Although there is potential to redevelop Women’s services across the City of Bristol, no immediate plans are being considered. The services we provide today for women are of high quality and meet the national agenda to offer choice for mothers. We see no imminent changes to how maternity services will be offered.

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Core clinical Services (CCS)

Key issues going forward include growing demand for all services and the need to innovate for change working as an enabler for all Directorates. Growth is anticipated to be 6-10%, an increase in interventions per patient episode have been identified, there is an increased demand for accurate and timely reporting and national guidelines, for example for earlier detection of cancer, place additional pressures on CCS. Issues exist in the availability of staff to support highly complex surgical work. Despite the number of radiologists per million population for NBT being average, the more complex casemix requires an increase in the workforce. Additional capacity required for imaging (CT and MRI scanning is reaching capacity), pathology, pharmacy and therapies. Due to the good quality outcomes at NBT in relation to for example trauma and also vascular centralisation ITU activity has increased. Clinical shifts in interventions (for example open to endovascular aortic aneurysm surgery) and technological advances impact on the required skillmix of CCS.

In relation to quality a focus going forwards includes access to more accurate and timely data (data profiling) which includes working towards minimising risk in the interface between secondary to primary care, succession planning, meeting national standards and guidance (eg emergency laparotomies), achieve effective elective and non-elective balance in workload, improve patient pathways with all clinical directorates and reduce duplication of interventions.

Clearly CCS requires strong integrated links with all other directorates. The vision going forward is that information is shared across directorates and early engagement achieved, pathways are evidence based and reflect models of good practice, prioritisations of ICU discharges to improve patient flow, improved outpatient boking efficiency, staff developed to support highly complex surgery.

Overall aims are to develop a sustainable and skilled workforce (for example interventional radiology); work with other directorates to encourage a uniformity of approach in relation to facilities and support staff to the benefit of patients and patient flow whilst also enabling individual Consultant practices to continue; encourage patient pathway orientated planning to reduce length of stay and ensure right care received in the right place at the right time; improve patient flow by facilitating discharges (eg pharmacy), improving ICU bed availability and reducing unnecessary admissions; shift from elective to emergency support ensuring appropriately skilled workforce in place.

Research and development

Feedback from NBT’s Joint Director of Research with University Hospitals Bristol

1) How would you describe the current situation at the Trust – what research do we do / what are we good at / what contribution does it make?

• We’re in a strong position with good engagement across the organisation. Some areas have stronger engagement than others but our overall position is good. • We are good at research in trauma, urology, MSK, obstetrics, neuroscience (including movement disorders, multiple sclerosis and Alzheimer’s disease) ED, microbiology and diabetes. We are growing in stroke, cardiovascular surgery, dementia and plastics. We have research active staff in every directorate and all of our regional specialities are delivering research.

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• Our Clinical research centre (CRC) is attracting new and increased commercial research activity. It is a unique facility providing clinical space specifically for research • We are academically strong in a number of areas improving our links with Universities, our reputation, our ability to bring in funding and also increasing the calibre of applicants we attract. • Income has been used to increase the capacity and technology of various clinical departments including pathology and pharmacy. • Organisations involved in delivering research have better mortality outcomes than those that don’t • R&I deliver care for approximately 5000 patients per year contributing to outpatient and staffing capacity • Research trials give patients access to novel treatments and our ground breaking research projects that are trialling novel and new interventions attract patients from across the UK (eg GDNF trial) • Outcomes from NBT led research in surgery, msk, microbiology and obstetrics have been used to update NICE guidance allowing evidence based care improvements

2) What would be your ambition for how the research department will evolve over the next 5 years

• We are about to start a large piece of stakeholder engagement work to develop our new research strategy. We will engage with staff and patients from across the organisation and region in order to inform our strategy. Our ambition is to further increase the research we do at the same time as addressing issues that are important to our local community. • We are running a patient survey of research participants to assess their experience of our service and will use this plus our friends and family results to improve the service we offer. We aim to increase patient satisfaction and make research more visible to patients. • We will engage more with service leads to embed research in to daily practise at NBT and increase the amount of service delivery research at NBT improving our research profile and having a direct impact on NBT services. This includes implementing research into clinical practise and evaluation. This is something we don’t do well today but should improve. • We will broaden our research portfolio to increase the number of observational projects we do, complementing our interventional trials whilst increasing the number of patients with access to research. • We will match our research portfolio to disease incidence in the local population to increase the number of and equity of access of patients to our research studies – Bristol has a high prevalence of diabetes and obesity in common with most other inner city, heavily populated areas. • We aim to focus our success in diabetes and endocrinology research and expand to deliver research in obesity as we anticipate this will be named as a priority area for national research – trials will include looking at most cost effective treatments – surgery is proving successful at the moment. Aim to find ways to reduce hospital attendances for those with LTCs. • We need to implement existing research

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• We will increase commercial use of the CRC. Pathology is running consultancy work through the CRC and we can further increase the out of hours commercial use increasing income and gaining a reputation as a centre for commercial research work. • We will increase links and collaborations across the region in order to direct patients more effectively in to research increasing the success of each organisation while minimising competition between organisations. • We will focus on areas of strength and increase the number of research grants awarded to NBT. We will engage with service leads, patients and our university partners to ensure that we’re asking the right questions and doing research that will benefit the service as well as patients. • Board template has measurements for R&I – numbers of patients in clinical trials, amount of income generated, numbers of successful research grants – could set targets based on these.

3) What would you want the Board to support / do differently to achieve your ambition?

• Continued message about research being a core activity of NBT to increase research visibility and also encourage research to be implemented and embedded in daily care. • Encourage service managers to engage in service delivery research. Current issues in their services could be addressed with national funding to allow NBT to innovate and embed evidence based improvements. Define what we mean by Innovation and where it “sits” organisationally and within directorates. • Continue to publicise research to our patients and other stakeholders. Increase the message that NBT is a research active organisation • Continue to represent NBT interests in regional networks (eg BHP, CLAHRC, AHSN and CRN) and help celebrate our successes • Add a research category to the annual NBT nurse awards. • Investing in research leads to better patients outcomes, increases the ability to attract and retain staff, patients have higher satisfactions scores

4.2 NBT self-assessment

In order to understand our current performance well, NBT senior leaders undertook an analysis of the Trust’s strengths, weaknesses, opportunities and threats (SWOT analysis). The Board has also undertaken an assessment of the environment in which the Trust operates, taking account of known legislative, policy and regulatory updates as at August 2015.

Key messages from this analysis have helped shape our strategic choices including the need to:

- build on our areas of clinical excellence and specialist expertise - develop as a system leader to drive changes to service and pathway design – work proactively - lead on the research agenda

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- work with patients to enable self-management where appropriate - develop our workforce - improve our relationship with stakeholders - improve our information and intelligence function - improve our succession planning - identify and remain engaged in plans regarding health and social care budgets, specialised commissioning budget changes - engage in whole healthcare system planning regarding the NHS Five Year Forward View to manage issues such as increasing demand, public expectation and competition - ensure cross-directorate planning where appropriate.

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References (to be completed)

NHS FIVE Year Forward View – NHS England October 2014 NHS 2016/17 Planning Guidance – NHS England December 2015 Improving Outcomes: a strategy for cancer – fourth annual report - https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/388160/fourth _annual_report.pdf Dignity must not be denied – Macmillan Cancer Support - http://be.macmillan.org.uk/Downloads/Make/GettingInvolved/GeneralElectioncampaign/GEDi gnityMustNotBeDenied.pdf Consumerisation, the next big trend in healthcare – IBM – Andy Collett - http://healthcare.governmentcomputing.com/features/consumerisation-the-next-big-trend-in- healthcare-4157263 Achieving world class cancer outcomes – Report of the Independent Cancer Taskforce - http://www.cancerresearchuk.org/sites/default/files/achieving_world- class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf National Review of Adult Elective Orthopaedic Services – Professor Tim Briggs - https://www.boa.ac.uk/wp-content/uploads/2015/03/GIRFT-National-Report-Mar15..pdf Public Health England – Adult Obesity and Type Two Diabetes - https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338934/Adult_ obesity_and_type_2_diabetes_.pdf The Kings Fund – Long Term Conditions and Multi Mobidity - http://www.kingsfund.org.uk/time-to-think-differently/trends/disease-and-disability/long-term- conditions-multi-morbidity When Clinicians Lead – McKinsey & Company - http://www.mckinsey.com/insights/health_systems_and_services/when_clinicians_lead Personalised health and care 2020 / using data and technology to transform outcomes for patients - https://www.gov.uk/government/publications/personalised-health-and-care- 2020/using-data-and-technology-to-transform-outcomes-for-patients-and-citizens

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Trust Strategy

2016/17 to 2020/21

Contents:

1. Introduction

2. NBT today

3. The challenges we face

4. Our values and vision

5. Strategic themes and delivery plan

6. Next steps

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1. Introduction North Bristol NHS Trust is a centre of excellence for healthcare in the South West and one of the largest hospital trusts in the UK. The environment and context in which we provide services is changing rapidly and this strategy will ensure that the Trust continues to provide high quality service to patients within the increasingly complex environment. The Trust also has broader contributions to make to the health of the population that we serve and the wellbeing of our staff.

This strategy has been developed for the period 2016-2021 to provide focus and clarity of direction for the organisation and our stakeholders. It sets out a vision for the future and the strategic themes that will ensure the vision is realised. The Trust strategy aims to deliver a successful, sustainable and resilient organisation playing a full part in an effective health and care system for the population it serves.

The successful opening of the Brunel building on the Southmead Hospital site in May 2014 has resulted in a transformative improvement to the hospital infrastructure and the Trust is now planning the next phase of improvements to the services we provide. The organisation combines both high quality specialist care for some of the sickest patients in our region and general hospital services to the local populations of South Gloucestershire, Bristol and North Somerset. The Trust also works with other hospital providers in the delivery of networked care for example hosting the Severn Network Major Trauma Centre, the South West Major Arterial Centre, the South West Burns Network and South West Neuromuscular Network. The Trust works in partnership with University Hospitals of Bristol NHS Foundation Trust to provide coherent, high quality specialist services for this region.

The complex circumstances in which we work mean that the performance and quality of our delivery is not yet at the standard that we would expect, which was demonstrated in the report of the Care Quality Commission following their inspection in November 2014 which assessed the Trust as ‘requiring improvement’. Our improvement work must address our financial position, the delays in accessing our services and continue to develop the highest standards of patient care to deliver excellent outcomes and patient and carer experience that we are proud of.

The Trust is midway through a financial recovery plan designed to deliver a surplus by 31st March 2018. However the financial position in 2015/16 is not delivering in line with the recovery plan and it will be necessary to reassess and reshape the future projections. The plan assumes that elective activity will grow at 1% per annum other than in Orthopaedics which is expected to grow more quickly. The plan also assumes that non-elective activity will stop increasing as a result of increased care in community settings offsetting increases in demand as a result of demographic change in the population.

This strategy has been developed following detailed analysis of the Trust taking into account activity, quality, performance, outcomes, clinician, staff and patient views. We have taken a fresh look at the Trust, at the opportunities facing us, the challenges that can be foreseen and at our strengths and weaknesses building upon feedback from our senior leaders.

Our overarching strategy will be supported by a set of enabling and supporting strategies including Quality, Research and Development, Information Management and Technology, Workforce, Estates and Facilities, Communications and Stakeholder strategies. The communications and stakeholder

strategies will ensure that the views of key stakeholders, including the local population, are fed into strategic implementation plans to enable effective and targeted delivery of the strategy.

The Trust Board will monitor and evaluate the delivery of the Trust strategy through a set of key performance indicators and outcome measures. The strategic themes will be reviewed on an annual basis to ensure they reflect an appropriate direction of travel as the environment in which we work and population we serve continuously evolve.

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2. North Bristol NHS Trust today 2.1 Our Clinical Services

North Bristol NHS Trust is a provider of acute and specialist health services and includes services that reach in to the community for example in maternity care and diagnostics. The Trust has 1,050 hospital beds and employs 8000 staff. In financial year 2014/15 the Trust received an income of £552m. Income for patient care was split 31.6% for specialist services commissioned by NHS England and 63% from the Clinical Commissioning Groups of South Gloucestershire, Bristol and North Somerset.

In 2014/15 the Trust treated over 51,000 inpatients, including day patients, as well as caring for over 85,000 people in our Emergency Departments. More than 6,000 babies were born at Southmead, Cossham, at home, or elsewhere in the community and we carried out approximately 295,000 outpatient appointments.

The Trust provides General Hospital services to our local population and a range of specialist services that serve a wider and more regional population. The General Hospital services require a range of skill sets and infrastructure that can be found in most acute hospitals. The specialist services have additional needs including particular needs for diagnostics and equipping.

Our services have evolved to meet the needs of patients and commissioners. Working with University Hospitals Bristol NHS Foundation Trust a number of significant transfers of services have been undertaken between the two major acute providers in the City of Bristol that ensure care is provided in the most appropriate setting. Where skills are in short supply, consolidation has taken place to improve patient outcomes. The arrangements have always given due regard to the need for local provision where possible to ensure a good patient experience. As a result of the changes made, the Trust hosts the Severn Region Major Trauma centre supported by seven major trauma units in other providers. The Trust provides the Major Arterial Centre to the vascular network which is delivered through a ‘lead provider’ model. This includes 24/7 access to a specialised multidisciplinary team which has access to a £1.5 million ‘hybrid operating theatre’.

The plastic surgery service provides a highly specialised team experienced in the most complex cases in adults and children (delivered at the Bristol Children’s Hospital). The South West UK Burn Care Network is hosted by the Trust and covers South and Mid Wales, Devon, Cornwall, Somerset, Wiltshire, Hampshire, Scilly isles and South Gloucestershire.

This grouping of specialist surgical services including neurosurgery has established the Trust as an organisation that treats the most complex surgical emergency patients.

Consolidation of urology and breast care services in addition to established skin cancer, brain cancer and lower gastro-intestinal services has resulted in a centre of excellence for complex cancer surgery. The Trust also provides diagnostic and specialist components of upper gastro-intestinal, lung and gynaecology cancer care. The Trust does not provide radiotherapy or oncology services and works in partnership with University Hospitals Bristol NHS Foundation Trust to ensure smooth pathways for patients who require these services following or in conjunction with surgical intervention.

Emergency care and cancer care have high demands for diagnostic specialties in both pathology and radiology. In recent years the Trust has made significant investments in two buildings to house pathology services. The second of these will open in 2016. Once open they will be occupied by all of

the Trusts pathology services together with a city wide consolidated service for histopathology and in partnership with Public Health England a microbiology service that provides for Bristol and Bath. The Trust has a long standing genetics laboratory with a national reputation. The constellation of general pathology services around a continually developing genetics expertise provides an opportunity to be at the forefront of technological changes that will deliver the personalised medicine expected in the future.

Radiology underpins all of the Trusts clinical services. The Trust has continued to invest in new technologies for both CT and MRI and demand for these services continue to rise. Working in partnership with Alliance Medical the Trust will house a Positron Emission Tomography (PET) scanner from 2016 which will improve diagnostic capability for cancer patients in Bristol. Increasing amounts of what was formerly surgical work is now being under taken by Interventional Radiology. It is expected that this trend will continue and because the skilled radiologists are in short supply it is likely that Interventional Radiology services will be relatively centralised in the health care system. North Bristol Trust requires a strong interventional radiology service to deliver its complex surgical work and is already taking patient referrals on a regional basis.

In addition to the needs of the Trust, diagnostics underpin much of health provision in primary and community care. The needs for earlier diagnosis particularly for patients with suspected cancer will increase demand for diagnostic testing and for expert interpretation of results that supports decision making in General Practice. Ease of access to diagnostics will be an important part of future provision. This represents a further opportunity for NBT to make a positive contribution to the health needs of the local population.

The Trust maternity service is a fundamental part of our provision for our local population. It has academic strength and an international reputation for expertise in safe, team based care. There is much that the rest of the Trust as well as other organisations can learn from its success. Associated with our Maternity services we provide a specialist commissioned level 3 neonatal intensive care unit which specialises in extreme premature babies working within a provider based neonatal intensive care network.

The services we provide today create an inter-dependent whole. For example trauma service provision requires complex orthopaedic services. This makes North Bristol Trust the natural home for one of the largest elective orthopaedic services in the country providing regional, specialist complex elective care as well as services to the local population. Urology and vascular services support renal failure treatment and kidney transplantation.

NBT’s Richard Bright Renal Unit at Southmead Hospital is the largest of its kind in the West of England. It carries out >100 kidney transplants every year and has led the way with laparoscopic kidney transplantation, spousal donation and non-heart-beating donor transplants.

NBT’s Neurosciences Department is the regional centre for neurological services for the West of England, including Neurosurgery, Neurology and Stroke, Neuropsychiatry, Neurophysiology, Neuroradiology and Neuropathology. The department leads the South West neuromuscular network.

The interdependency of services suggests there is limited change to the portfolio that could be made without impacting on performance of the Trust as a whole. The breadth of service delivery creates NBT’s unique identity and is illustrated in figure 1. As a result of this service delivery model the complexity of patients attending NBT has been and will continue to increase.

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Figure 1: NBT today

Musculoskeletal Neuroscience Renal

Trauma Centre Arterial Centre Local Hospital Emergency Medical,Surgical Cancer Surgery and Maternity services Surgery and care

Plastics/Burns

Diagnostics

2.2 Future demand

As specialist services consolidate within networks and with demographics indicating increased numbers of elderly people and others living with more than one long term health condition, the Trust can expect increased demand for its services. Our activity projections suggest that demand for elective work will continue to increase at 1% per annum for most specialties, except orthopaedics which is expected to grow 5% in 2015/16. Given the resource and capacity constraints in the health system, the Trust will work with our commissioners to deliver more care in the community and closer to home and also work with patients to enable self-management. The aim is to minimise increases in demand on hospital services for non-elective (emergency) activity.

There are opportunities to grow some of our specialist services if national drivers to improve cancer identification and treatment lead to more funding in this area. Other conditions such as stroke care may consolidate within tertiary centres. In order to meet any additional demand, we expect to improve our networks in the region ensuring that patients are repatriated closer to home as soon as they no longer require the necessary specialist care.

2.5 Market analysis and context

The Trust operates in two main healthcare markets:

• Local acute services – predominantly for the population of South Gloucestershire, Bristol and North Somerset; and • Specialist services – primarily in the South West of England and in some cases, national.

The Trust is one of two acute trusts in the Bristol area. Over recent years, there have been a number of service changes between NBT and University Hospitals Bristol NHS Foundation Trust. No further major changes are planned and we therefore expect our market share to remain fairly stable.

Other acute providers in the region are Royal United Hospitals, Bath which predominantly serves the population of Bath and North East Somerset; and Weston Area Health, which serves the population of North Somerset. Both trusts refer complex or specialist cases to North Bristol Trust. A significant review of the models of care for hospital services in Weston Super Mare is to be undertaken in 2016 with a view to ensuring sustainable, high quality services for this population. The review may impact the share of care that is provided by health organisations in Bristol including NBT. We do not expect a change in patient flow with respect to Bath.

The wider Bristol area also hosts a number of private sector providers which all provide additional elective capacity to the NHS.

2.3 Workforce

The Trust employs 8000 staff including:

Medical and Dental 853 Admin and Estates 1620 Healthcare and support staff 1630 Nursing and Midwifery 2210 Scientific and Therapy 1373

Following the move to the Brunel hospital building, the voluntary rate of staff turnover has increased and a number of individuals with important skills and experience have left the organisation. The Trust has concentrated on filling gaps in staffing with permanent appointments to reduce dependence on temporary staffing and on developing the necessary skilled staff, for example in theatres and intensive care. Understanding and improving management of sickness absence and all aspects of staff well being are also areas requiring continued focus.

The staff survey in 2014/15 was taken after the hospital move and was a disappointing result with the Trust being in the worst 20% for 10 of the 20 questions. Subsequent information from the staff Friends and Family tests, and the 2015/16 staff survey have shown an improvement but the board are aware that there is more to do as the performance and quality of the service we provide is dependent upon a well motivated and highly skilled work force.

The Trust plays an important role in developing the health care workforce of the future. We provide education, teaching and training for doctors, nurses, midwives, allied health professionals and healthcare scientists who work at the Trust and we are an established, respected centre for training healthcare students.

Our Apprenticeship Centre is nationally recognised as an employer based education programme with a Skills Funding Agency apprenticeship contract. We see our apprenticeship programme as the start for many people who go on to fruitful health care careers at all levels, within NBT and the wider health and social care economy.

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2.4 Research

NBT has strong links with the University of Bristol and the University of the West of England (UWE).

NBT has a significant and growing research portfolio with more than 280 researchers delivering 450 research studies in the past year, including 48 commercial trials. We have research strengths in trauma, urology, MSK, obstetrics, neuroscience (including movement disorders, multiple sclerosis and Alzheimer’s disease), Emergency Medicine, microbiology and diabetes. We are growing in stroke, vascular surgery, dementia and plastics. We have research active staff in every directorate and all of our regional specialities are delivering research.

Research, and the associated teaching and learning, supports delivery of care for approximately 5000 patients per year contributing to staffing capacity. Research trials give patients access to novel treatments and we lead ground breaking research projects that are trialling new interventions attracting patients from across the UK. Outcomes from NBT led research in surgery, musculo-skeletal services, microbiology and obstetrics have been used to update national guidance demonstrating translation in to care improvements.

3. The challenges we face

3.1 Population changes

The demand for healthcare continues to rise. Our populations are increasing, with steady growth in the number of older people and those living with one or more health conditions. There is an increasing amount of information available to people in need of health care. We can expect increasingly informed patients exercising choices in where their care is provided. Patient voices and more consumerism within health will inevitably lead to changes in the way we interact with and respond to the needs of our patients.

Some of the challenges for the future are set out below:

• An aging population with increasing numbers living with dementia and long-term conditions; • Greater public expectations – 7 day access to care close to homes and a co-ordinated approach to health and social care; • Increasing complexity of care required by individual patients to achieve best outcomes; • Increasing complexity of inter-dependent services within the Trust; • Requirement to reduce variation in the quality of care; • Greater emphasis required on keeping people healthy and in charge of their own care; • Limited increase in real terms budget for the NHS – the estimated gap between NHS spending and resources available will rise to £22bn over the next 5 years; • Commissioners and Local Authorities with financial pressures and competing demands; • Working with primary care and other services so that our services form part of integrated care; • Innovating and co-operating across organisational boundaries both within and beyond NBT; • Population growth and the need to address inequalities in life expectancy; • Growing numbers of patients with multi-morbidities including cross-cutting clinical conditions such as alcohol-related conditions and mental health conditions; • Use of NHS funding for providing health care in the community through the Better Care Fund;

3.2 Efficient use of the Trust’s resources

The major immediate challenges facing the Trust are to improve the flow of patients through the hospital by reducing bed occupancy, balancing capacity to deliver against the demand and achieving this within the financial resources available. Our hospital beds should only be used for those patients who will gain the most value from what we offer. We know that too many frail and elderly patients are cared for in our hospital beds when there are more appropriate, cost effective environments that would better meet their needs.

All our services need to be delivered to a high standard of quality and efficiency in order to manage the anticipated demand into the future. To succeed, we must: • Ensure that all planned care is delivered at upper decile productivity; • Focus on increasing prevention and avoidance of admissions; • Use our networks efficiently to make sure that patients are returned to referring hospitals as soon as their needs can be met there; • Work with partners in the health system to manage patients with rehabilitation and re- enablement needs;

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Increased productivity must maintain our ability to care for increasingly complex patients as well as releasing more capacity. To efficiently expand our capacity it is likely that we will need to use our hospital resources over a longer working week (6 to 7 days) and work in partnerships with other providers to share the workload.

We must use our strength in diagnostic services to support clinicians in the Trust, in primary care and community care to define the health problems of patients and ensure they receive the right care in the right place rapidly.

3.3 Commissioner priorities

National priorities: • Securing additional years of life for the people of England with treatable mental and physical health conditions; • Improving the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health conditions; • Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital; • Increasing the proportion of older people living independently at home following discharge from hospital; • Increasing the number of people with mental and physical health conditions having a positive experience of hospital care; • Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community; • Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care;

Our key commissioners have also identified the challenges that they need to be addressed:

South Gloucestershire: • The size of the population of South Gloucestershire is increasing; • There is a steady growth in the number of older residents and those living with one or more health condition; • The financial environment is challenging which means that more must be achieved with the resources that are available; • Local people need to be supported to achieve and maintain good health and wellbeing; • More people are living with heart disease, diabetes, hypertension, dementia and obesity; • A key objective to drive integration of out-of-hospital care so that patients are better managed in the community;

Bristol: • Tackling the stark health inequalities between affluent and deprived areas; • Addressing the health needs of a rapidly growing, young and ethnically diverse population; • Improving the health of children in care and of disadvantaged children; • Tackling premature death caused by cancer, which remains the biggest killer of people aged under 75 in the city (38 per cent); • Addressing the health needs of those who are living longer and with long-term conditions such as dementia, especially those aged over 75 who are living alone;

• Improving partnerships between GPs, community health and social care workers; • Improving pathways for Long-term conditions, especially diabetes; • Improving health services for patients with conditions caused by obesity, smoking and rising rates of alcohol consumption; • Commissioning health promotion services to reduce these problems in the future; • Improving access to healthcare for Bristol’s increasing black and minority ethnic (BME) population, working closely with the voluntary and community sectors;

The NHS Five Year Forward View and NHS Planning Guidance (2016/17) will guide local commissioner plans and the Trust’s priorities over the next five years. Place based health planning for populations, requires specification of a local Sustainability and Transformation Plan and leaders in this locality have decided that our population for planning purposes will be Bristol, North Somerset and South Gloucestershire (BNSSG). The plan will be submitted to NHS England in June 2016 and NBT is involved in its development. Since a significant proportion of work delivered at North Bristol NHS Trust is for a wider population in the region, The Trust will also engage with specialist commissioners and organisations in provider networks to determine sustainable plans for these services.

Specialised Commissioning challenges – Bristol, North Somerset, Somerset and South Gloucestershire (BNSSSG) • A diverse population spread across urban and rural settings with variations in levels of ethnicity, inequality and access; • A higher proportion of population aged 65 or over compared to the rest of the UK; • Increases in population in the South West, particularly in those aged between 65 and 69; • A need to improve rates of premature mortality from liver disease; • A need to reduce incidents of suicide and injury poisoning; • Managing the likely increases in incidence of cardiovascular disease due to smoking, high alcohol consumption and obesity; • Reducing the above national average incidence of malignant melanoma in the South West; • Managing specialist commissioning within a challenging financial environment.

3.4 Financial Performance

NBT’s Long Term Financial Model sets out the financial plan to 2020/21. To return to a sustainable position, the Trust has set out to achieve a £150m transformation programme to be delivered over the next 5 years. The current plans show the Trust returning to a surplus in 2017/18. The recovery of the Trusts financial position is now likely to be extended in light of the 2015/16 out turn position. Re- working of the financial model will be an annual event to take in to account the in year position and progress with implementing the strategy.

The forecasts have the following key assumptions:

• Elective activity growth at 1% year 1 (0.2% following years), excluding Orthopaedics at 5% year 1 (2% following years); • Non elective is offset by QIPP; • No explicit impact of Seven Day Service assumed with additional funding or costs; • Tariff changes in 2016/17 onwards are overall revenue neutral to the Trust (excluding tariff deflator / inflator);

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• Post 2015/16 all increases in income are assumed to have 100% marginal cost either to support the savings programme or to fund outsourced activity; • The reduction in backlog income in 2016/17 (£2.5m) has an equal effect on expenditure; • Ceasing to provide CCHP has a favourable real financial impact of £0.9m per year;

3.5 Operational Performance

Both before and after moving services to Southmead the Trust has faced challenges in balancing capacity and demand. Particular concerns relate to:

• Non-elective emergency pathways demonstrated by poor performance against the 4 hour standard over a prolonged period • Orthopaedic, neuroscience and urology elective and cancer capacity demonstrated by performance on the RTT and cancer standards • 52 week waits for spinal surgery

3.6 Quality and Safety of patient care

The Trust board is committed to providing a high quality of service to our patients and to transparency of information about quality. An Account of the Quality of our services is published annually and contains a review of the year and identification of the priorities for quality improvement.

The Hospital Standardised Mortality Ratio and Summary Hospital Mortality Indicator have steadily improved since the move into the Brunel building and continue below the national average. There has been significant improvement in the mortality statistics for patients admitted at weekends and these are now no different to those for weekday admission.

Through our Clinical Audit Committee and our Quality Surveillance group the Trust has systems for monitoring clinical outcomes. As described in our Quality Accounts the Trust gives particular priority to contributions to National Audit and to National Registries. This allows clinical teams to compare the outcomes of care at NBT with those in other centres.

The safety programme is focussing on developing a culture of ensuring that patients always receive all of the evidence based care that they need and that there is an intolerance of error impacting patient outcome.

The priorities for safe care identified in the last four years Quality Accounts are:

• Infection control • Preventing deterioration of acutely ill patients including sepsis and acute kidney injury • Reducing pressure ulcer incidence • Reducing mislabelling of blood tests • Safe systems of care in operating theatres • Improving nutrition assessments • Ensuring medical records and bed side patient documentation are in place • Improving quality and timeliness of discharge information

3.7 Patient Experience

The Trust assesses the experience of patients through the annual national patient surveys including the cancer experience survey, through the monthly friends and family tests and through investigation of complaints. Performance in the patient and staff surveys demonstrates areas for improvement, particularly in relation to customer care and staff engagement.

Although many patients were complimentary about the new environment in the Brunel building there were also difficulties for patients caused by the disruption of the move and these were reflected in a decline in patient experience in the subsequent months. A number of actions have been taken to improve the experience of care including roll out of televisions to the single rooms, improvement to parking arrangements and the support from the volunteer ‘Move Makers’.

The priorities for patient experience identified in the Trust Quality Accounts over the past four years have been:

• Providing patients with good information about their care • Improving the experience of cancer patients • Increasing response rates and learning from the Friends and Family tests • Improving care for patients with Dementia

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4. The Trust values, vision and strategic objectives 4.1 Trust Values

During 2012, in consultation with staff the Trust developed a set of values that represent what we stand for at North Bristol NHS Trust. There is extensive research which links values to staff engagement, good outcomes and a good experience for patients. The effect is strongest when the values of individual employees are aligned with the organisation’s values. The values that we developed are:

• Putting patients first; • Working well together; • Striving for excellence; and • Recognising the person.

Description of our values helps staff to consider what they mean to them as individuals and how they can be used to improve the services they deliver.

4.2 The vision for the future

At NBT we will realise the great potential of our organisation by our skilled and caring staff delivering innovative, high-quality services in state-of-the-art facilities. This will ensure excellent clinical outcomes and an outstanding experience for our patients.

It is our aim to provide excellent clinical outcomes that are comparable to the best in the world, delivered safely so that every individual patient has the best chance of a good outcome and do so within an outstanding experience for our patients. We want to be an organisation that reliably provides best practice care and treatment and be part of a local system of healthcare that provides high quality care to patients with an efficient use of resources. We want to be nationally recognised for our specialist services, leading regional provider networks and developing our services through a combination of clinical excellence, research output and high quality training. We acknowledge the need to implement new ways of working within the tight financial environment that faces all NHS organisations and understand that we will need to improve the care we offer whilst delivering this in a more productive and efficient way.

In 5 years we will:

Have a reputation Be a great for clinical Have an innovative organisation that excellence with approach to our people are patients at the heart delivering care proud to work for of everything we do

5.Strategic themes and delivery plan To deliver our vision and strategic aims the Trust Board has chosen the following themes that will form the basis of our plans over the next 5 years:

1) We will change how we deliver services to generate the capacity to meet the demands of the future.

In order to maintain our current portfolio of clinical services, we will need to meet the challenges of the future by managing our resources more efficiently and changing the way we deliver care, particularly for our frail and elderly patients and those with long term conditions.

2) We will become one of the safest Trusts in the UK

We will improve delivery of care for our patients by continuously working to increase consistency and reliability of our services. We will become expert at working together in teams and as a ‘team of teams’ to always provide the right care for individual patients. We will then be one of the safest trusts in the UK, providing outcomes that match the best in the world.

3) We will treat patients as partners in their care

We will change our relationship with patients so that they are empowered in making choices for the planning and management of their own care. This will result in significant improvements in how patients experience the services we offer. We will invest in culture change and education to empower patients.

4) We will create a workforce for the future

We will develop a flexible and multi-skilled workforce that will provide the staffing we need for the future. Our highly skilled teams will be capable of adapting to the changing and complex needs of our patients and work together to deliver the vision of the Trust. We will invest in and nurture talent and high performing teams. We will care for our staff, prioritising their health and wellbeing so that NBT becomes a NHS employer of choice.

5) We will empower our clinicians to lead

Our organisation will be clinically led, with clinical staff taking responsibility for their area of work including clinical quality, operational performance and use of resources. Clinical leaders will together lead the organisation toward the strategic vision.

6) We will maximise use of technology so that the right information is available for the key decisions

We will innovate and transform our services through an increasing use of technology to drive better information and better outcomes for patients. Our clinicians will have accurate and relevant data to support them to deliver better care to individual patients. Our leaders and teams will have the information they need to ensure the Trust vision is realised.

7) We will increase our research contribution

Future improvements in care are dependent on development of today’s research. The Trust will increase its research output through supporting our current strengths and working with others in Bristol

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Health Partners. We will develop our systems for ensuring rapid introduction of new evidence based care for the benefit of our patients.

8) We will play our part in delivering a successful health and care system

We will act as leaders within our healthcare system using our clinical knowledge and experience to ensure the most effective care for patients. This will require us to work with partners to ensure that patients are treated in the right place at the right time and that the most appropriate organisation provides the care that patients need. We will step up to play a wider role in making the whole healthcare system successful.

Sections 5.1 to 5.8 describe the strategic themes in more detail setting out our ambitions for 2021 and our priorities for action during 2016/17.

5.1 Strategic Theme ONE:

We will change how we deliver services to generate the capacity to meet the demands of the future.

We aim to develop a long term culture of continuous improvement that will ensure all of our patients receive the best possible care on every occasion they need it. We will have an organisational culture which prioritises patients and quality care above all else, with clear values embedded through all aspects of organisational behaviour. We will prioritise achievements against national and local performance targets including increasing patient flow and achieving performance targets notably in relation to ED, referral to treatment and transfers of care and delivery against CQC hospital inspection recommendations.

Ambitions for 2021:

• We will be achieving the highest level of rating from our regulators; • Delivering services that meet all NHS constitution and national cancer minimum standards; • Our operational performance will set the standards to which other Trusts aspire; • Specialist services will meet best practice guidelines for speed of access to care; • We will rapidly repatriate specialist patients back to referring hospitals and health communities; • Our services will have the flexibility to manage patients, or support self-management, promptly when they have urgent needs; • We will be working in partnership with GPs and community providers so pathways for patients with long term and complex conditions (including the frail and elderly) minimise hospital attendances; • We will have maximised the use of the hospital infrastructure efficiently across the week; • We will have diagnostic services that support personalised care and ensure that patients receive the best care, first time and in the most appropriate setting, away from the hospital if possible; • Our diagnostic services will have expanded our offer to an increasing number of providers in both acute, community and private sectors; • We will be delivering service line costing so that we understand how much each of our services cost and ensure costs do not exceed tariff income; • We will have eliminated our financial deficit, offering a portfolio of services that together deliver a financially sustainable organisation; • We will have improved the maternity estate ensuring accommodation is fit for purpose; • We will lead networks of providers to deliver complex care that is centralised where necessary but close to home when possible.

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5.2 Strategic Theme TWO:

We will become one of the safest Trusts in the UK

The Trust has a long standing commitment to improving the quality and safety of its services. Our aim is to provide high quality and safe care for every one of our patients, in every service and every time it is needed.

We will maintain our contributions to the National Clinical Audit programme that allow us to benchmark the outcomes of our care against other NHS organisations. The outcomes of the audits will be addressed with actions for improvement. There will be continued oversight of the outcomes of care including standardised mortality data so that we can triangulate quality information and take action promptly when needed to ensure patients receive the quality of care they need.

Looking to the future the requirements of healthcare will continue to change. We expect rapid development of new technologies that will continue to increase personalisation of medical interventions. Expectations of patients will continue to increase whilst available resources will remain significantly restricted. Quality improvement is therefore a continuous and long term requirement.

Ambitions for 2021:

• We will have a reputation for excellence with outcomes that match the best in the world; • We will have a culture that is intolerant of errors in care that impact on patients, having reduced harm events and errors to a minimum level that is best in class amongst UK hospitals; • We will have developed services that are all providing good outcomes of care in comparison to benchmarks and with measurable exceptional care in at least 10 specialties; • We will deliver services that meet patients’ needs for high quality care on any day in the year; • We will be delivering care in an appropriate, well equipped and clean environment; • We will be offering rapid access to error free diagnostic services that meet all regulatory and professional standards; • We will be a centre of excellence for quality improvement methodologies; • We will have reduced complexity of care by standardising according to patient pathway; • We will have developed team working that manages the complexity of individual patient needs and ensures that handovers between teams (inside and outside the Trust) promptly and reliably provides the necessary information enabling seamless care; • We will publish quality and outcome measures and share these at senior team meetings to ensure relentless focus of the organisation on delivery of the Trust vision.

5.3 Strategic theme THREE:

We will treat patients as partners in their care

We will change our relationship with patients and their families and carers so that they are empowered in making choices for the planning and management of their own care. This will result in significant improvements in how patients experience the services we offer. We will invest in culture change and education to empower patients.

The NHS 5 year forward view proposes that NHS organisations develop new relationships with patients and communities. We will aim to support people to manage their own health – staying healthy, making informed choices of treatment, managing conditions and avoiding complications so that their dependence on health care services is reduced. This will decrease attendances at A&E and reduce the amount of time patients spend in hospital. Patients could assume control of their care by directly commissioning blood tests and receiving the results themselves. Our services need to change so that patients have rapid access when needed and where possible, care and advice within their own homes.

Ambitions for 2021:

• We will have demonstrable service user involvement in all significant change projects; • Expert patient involvement will exist within service development for all long term conditions; • Patient held care plans will be in place including self-care advice for those with long term conditions; • Clear information and decision making will exist to support patient consent for all procedures; • End of life care will be provided in the setting of choice for patients and families with 24/7 access to expert support; • Follow up outpatient appointments will be reduced to those for whom the only option for good care is a face-to-face meeting in the hospital; • Outpatient capacity will have been released to provide rapid care to patients who need it urgently; • There will be respect for patient knowledge of the needs of their own long term conditions wherever they are cared for in the Trust; • Care will be rigorous and robust for patients with cognitive impairment, mental ill health or learning disability ensuring the opportunity for these individuals to contribute to decisions about their health is maximised; • A patient experience programme will effectively listen to patients, carers and staff and learn from their experiences; • We will have systems in place that actively seek patient feedback as well as responding promptly to complaints and teams that develop the services they offer in response to what patients tell them; • People who use our services will rate us highly and recommend us to others;

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5.4 Strategic Theme FOUR:

We will create a workforce for the future

We will develop a flexible and multi-skilled workforce that will provide the staffing we need for the future. Our highly skilled teams will be capable of adapting to the changing and complex needs of our patients and work together to deliver the vision of the Trust. We will invest in and nurture talent and high performing teams ensuring appropriate targeted training is available. We will care for our staff, prioritising their wellbeing so that NBT becomes a NHS employer of choice.

The Trust will ensure safe and competent staffing for our services now and in to the future. Our staff will need to be flexible to manage the rapidly changing environment of health care. Our future plans envisage a world where care could be provided outside current settings and with our clinicians working in partnership with colleagues in primary, community or social care settings.

Complex health care is delivered through teams who have the right knowledge, skills and approach to deliver for the needs of today and to continually develop new approaches for tomorrow. Our multiple teams must also work together so that patient care is not compromised by the barriers between teams.

North Bristol NHS Trust is the largest teaching trust in the South West with educational partnerships with our Universities, Colleges and a thriving schools and work experience programme. We have a National Skills Academy for Health Excellence Centre for the delivery of quality education for health care support workers designed to support progression within role and into higher education so that there is a sustained pipeline of future workforce. We want our staff to enjoy working at NBT and to feel valued and respected in their roles. We will embrace and support talent, providing opportunities for those who wish to progress their careers and achieve their potential.

Ambitions for 2021:

• Everyone at NBT will be well trained, motivated and well led - staffing establishments across all professional groups will reflect the skills required for safe care; • A culture will exist of upholding the values and standards of behaviour set by the Trust; • Strong partnerships will exist with the universities and Deanery to support training of the health care professionals fit for the future; • Reliable staffing to full establishment will be in place by minimising sickness, absence and voluntary turnover; • Recruitment processes will be in place that rapidly fill gaps in staffing with high quality replacements and thus minimise the requirement for temporary staff; • Demonstrable programmes in place that support staff health and wellbeing and engagement with metrics in place to assess their effectiveness; • The Trust will be the healthcare employer of choice in Bristol and nationally for a number of posts; • A talent management programme will be in place that ensures we attract high quality applicants for our posts, retains established staff and has equitable access for minority groups; • An organisational development programme will be in place centred on delivery of high quality patient care through effective team working and that equips our staff for managing the increasingly complex requirements of health care delivery.

5.5 Strategic Theme FIVE:

We will empower our clinicians to lead

Clinical leadership has been shown to lead to better solutions to the complex issues we face as a result of making decisions closer to the patient and delivering faster pace on culture change. NBTs Clinical Directorates are now led by a Clinical Director, General Manager and Head of Nursing. Our aim is to empower and enable our clinician leaders to take the key decisions on behalf of the organisation.

Ambitions for 2021:

• Clinical leaders will be accountable for delivery of quality care and for managing performance within the available resources of the Trust through the introduction of service line management; • Clinical leaders will have the time and skills required to lead the organisation in the areas for which they are accountable and develop succession plans for their roles; • Clinical leaders will be working together to ensure seamless patient care pathways; • Clinical leaders will be focussed on collectively delivering the strategic vision of the Trust as well as the success of their own areas of responsibility; • Clinical leaders will be driving the future success of the organisation as well as current performance; • Management teams will be skilled to support clinical leaders to be successful in their roles; • Corporate infrastructure and expertise will be supporting and enabling successful Directorate Management teams; • Our clinicians will be the key decision makers, playing an integral role in shaping clinical services • We will respond to NHS Five Year Forward View recommendations and enable self-management where appropriate.

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5.6 Strategic Theme SIX:

We will maximise use of technology so that the right information is available for the key decisions

We will innovate and transform our services through an increasing use of technology to drive better information and better outcomes and experience for patients. Our clinicians will have accurate and relevant data to support them to deliver better care to individual patients. Our leaders and teams will have the information they need to ensure the Trust vision is realised.

Decision making in health care is reliant upon good information both at the point that clinicians and patients make individual treatment decisions and when planning systems of care. Staff and patients are increasingly used to instant access to information in their everyday lives and they expect the same when considering health. Information technology has made many aspects of life more convenient for consumers and this must also be applied to their health and care needs.

An important element of self-care is enabling patients to monitor their own conditions. This is already available in some services and should be expanded as much as possible to enable patients to take control of their own conditions. There are also opportunities to use technology to provide services in different ways such as through remote consultations.

The new patient record system introduced in 2015 provides a basis for future clinical system developments and will support the move to a full electronic patient record. We aim to move NBT to a paper light organisation by 2018. With an increasingly complex evidence base there are opportunities to support good decision making using technology support such as rapid access to clinical guide lines.

Ambitions for 2021:

• Electronic systems will be in place that ensure that all the information required for individual patient care is always available to our staff in a format that supports their work flow; • Electronic patient records will be in place covering all aspects of patient care and with decision support in place to ensure care is of the highest quality; • Sufficient hardware devices will be available within the clinical environment to support use of the electronic patient record and resilient, reliable IT services; • Systems will be in place that enable connectivity across the health community to ensure rapid exchange of information to support care wherever patients are located within the health system; • Systems will be in place that support use of our clinical expertise in caring for patients at a distance such as virtual clinic consultations and advice and guidance for GPs; • Systems will be accessed by patients in order to understand their own data and support self-care; • Business Intelligence solutions will enable leaders to understand the functioning of the Trust in real time and include large scale analysis to support future development; • Business Intelligence will support demand and capacity analysis and service line reporting; • The Trust will demonstrate that population data such as the Joint Strategic Needs Assessments is incorporated in to future planning; • Data capture systems will support the service improvement methodologies including rapid cycle tests of change and key performance indicators; • We will have a fully electronic patient record and use technology to continuously improve how we work, support, treat and share information with our patients.

5.7 Strategic Theme SEVEN

We will increase our research contribution

Future improvements in care are dependent on development of today’s research. The Trust will increase its research output through supporting our current strengths and working with others in Bristol Health Partners. We will develop our systems for ensuring rapid introduction of new evidence based care for the benefit of our patients.

NBT has a significant and growing research portfolio and is one of the top 30 research trusts in the UK. We have established research strengths in musculoskeletal, infection and immunology, neurosciences and urology. Diabetes and respiratory medicine continue to be supported alongside emerging strengths in anaesthetics, obstetrics and gynaecology, vascular and stroke research.

NBT has worked with its partner universities and NHS trusts in the region to form Bristol Health Partners. This partnership has developed a shared research strategy and agreed common goals for translational and applied health services research. The mission is to integrate clinical service delivery, research and innovation, education and training across the organisations.

Bristol Health Partners has established 18 Health Integration Teams (HITs) which are cross- organisational, interdisciplinary groups set up to improve health outcomes. All HITs are aligned with the priorities of the partners and with the research, education and healthcare strengths in Bristol.

NBT aspires to become a world-leading research facility, to deliver high quality research of direct patient benefit and to embed a research culture in clinical service delivery.

Ambitions for 2021:

• We will have increased the academic output (publications and grant income) of the Trusts centres of research excellence; • We will have increased research income for the Trust; • Academic surgical specialties will be further developed; • We will have in place a programme of research that enables the maximum contribution of our patients to national research programmes; • Support will be in place for those who wish to develop a new research interest; • There will be continued engagement with the Bristol Health Partners programme of translational research; • Clinical teams will be engaged with evidence based best practice and systems that ensure rapid adoption of new practice supported by research evidence; • We will have a substantial research capability linking the results of our research to developing our services and implementing new evidenced base care rapidly.

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5.8 Strategic Theme EIGHT:

We will play our part in delivering a successful health and care system

We will act as leaders within our health and care system using our clinical knowledge and experience to ensure the most effective care for patients. This will require us to work with partners to ensure that patients are treated in the right place at the right time and that the most appropriate organisation provides the care that patients need. We will step up to play a wider role in making the whole healthcare system successful.

NBT is a major provider of health care in the Bristol and South Gloucestershire health economies. We acknowledge that we will need to build constructive partnerships with commissioners and other providers to ensure that we are working together for the benefit of our patients wherever they are in the health system.

The NHS 5 Year Forward View published in October 2014 states that the traditional divide between primary care, community services, hospitals, physical and mental health, is increasingly a barrier to the personalised and coordinated health services patients need. For good outcomes patients need all parts of the system to work seamlessly together. Our vision is that NBT will take a strong leadership role in the systems in which we work, with our clinicians driving changes in how care is delivered.

Ambitions for 2021:

• We will be contributing to a successful and sustainable health and care system; • We will have developed networks with other providers that ensure patients are managed in the right place at the right time to meet their needs; • We will have developed our leadership of provider networks that ensure excellence of specialist care for the population we serve; • We will have built strong relationships with all primary, community and secondary care providers to maximise the effectiveness of care and the patient experience; • We will be working with partners to ensure that patients are only admitted to hospital care if it is in their best interests, using advice and guidance from our experts to support community care where possible; • We will be working with partners to ensure that rehabilitation, enablement and social care are accessed rapidly and in the most appropriate location to meet patient need, including those with specialised rehabilitation needs; • We will have embraced opportunities to partner with other organisations to deliver care in more effective ways be they NHS, commercial or third sector; • We will be utilising our expertise to contribute to care in the community where possible; • We will be continuously developing new ways to deliver our services, designed for – and as much as possible by – the people who use them, working with partners to develop the health and care system as a whole.

6. Next steps In order to deliver our vision, we must successfully implement the commitments set out in this strategy.

Governance

The Board of Directors at North Bristol NHS Trust is committed to delivering the vision described in this strategy document with the aim of creating a strong, vibrant organisation which is at the forefront of healthcare delivery in the West of England. The Board will agree the milestones for delivery of the strategy and the key performance indicators that will track progress. The Board will review these at a minimum of three times each year. The strategy will be refreshed annually to ensure that it continues to meet the evolving needs of the population it serves and responds to technological and clinical advances.

In the annual exercise of agreeing the Trust and Directorate business plans and in the setting of budgets the Board will ensure that appropriate resources are directed at achievement of the actions and objectives within the strategy.

The Trust Management team (TMT) is responsible for development and delivery of the Trust strategy. Members of TMT will work with the Associate Director of Strategy and Medical Director in developing enabling and supporting strategies and workstreams.

The Board will work closely with the population is serves and the leaders of partner organisations to ensure there is a collaborative approach to whole system change and that NBT is making an appropriate contribution to system success.

Enabling and supporting strategies

The Trust strategy sets out the direction of travel for the organisation and the framework for the organisation to use when developing detailed plans. Each directorate and corporate area will develop their own Strategy Implementation Plans setting out specific actions for their clinical areas and services. This will result in relentless focus on delivery of the whole Trust strategy.

We have identified the following enabling and supporting strategies to ensure delivery of the overarching Trust strategy:

• Quality Strategy – to ensure high quality care across all specialties including delivery of safe and effective care and excellent patient experience; • Estates and Facilities Strategy – to ensure a high quality, flexible estate; • Workforce Strategy – to ensure sufficient flexibility, capacity and capability in the workforce including first class leadership and management capability; • Clinical Services Strategy – Forecasts future changes in the way clinical care is delivered so that accurate demand and capacity plans are developed; • IM&T Strategy – Real availability of information for individual patient care and high quality analytics for organisational functioning; • Research and Development Strategy – Builds research capability and ensures rapid translation of evidence base in to clinical care;

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• Stakeholder Strategy – Maintains good and effective relationships with partners and other key stakeholders; • Communications Strategy – Ensures views are collated and considered within strategy implementation; and tools developed to ensure consistent narrative and implementation of the strategy throughout the Trust;

Developing Strategy Implementation Plans Each year we will develop detailed implementation plans that will progress toward the agreed strategic milestones. Responsible individuals and lead teams will be identified for actions and these will be approved by the Trust Management Team.

Actions will be described in the form of Driver diagrams that clearly link individual actions to the overall strategic aim and hence to delivery of the Trust vision. This will enable the description of milestones and measurements that demonstrate the progress being made.

7. Conclusion

North Bristol NHS Trust is a provider of complex and acute healthcare for a large population in the South West of England. The organisation manages some of the most difficult medical conditions in an increasingly complex patient population with multiple comorbidities and long term conditions.

The Trust has the advantage of having invested in modern estate and equipment and the hospital building is designed to enable the complex patient care to a high quality and to provide an excellent experience of care for our patients.

Providing the high quality care to which the Trust and our staff aspire within the resources available is increasingly challenging and although the specific means for doing this may not yet be certain this strategy is designed to create an organisation equipped to find the solutions that result in continuing success over the long term. High quality team working and teams that work effectively together to achieve the Trust vision are fundamental components of our way forward.

The Trust is a component part of a complex health system. Working with partners in the system to ensure that the Trust is used for delivery of health care where it is most cost effective and adds most value to the populations health is also a vital part of our future.

Priorities for Year One (2016/17):

• Focus on operational management – improve efficiency and patient experience; • Improve operational management of outpatients, theatres and patient flow in general – achieve the cost improvement plan; • Improve the quality of and access to information within the Trust.

Priorities for Year One (2016/17):

• Ensure infection control systems and processes, including monitoring and reporting, meet required standards; • Reliably meet venous thromboembolism assessment quality standards; • Develop and monitor against quality outcome metrics;

Monitor and respond to patient experience feedback

Priorities for Year One (2016/17):

• Gain a more sophisticated understanding of patient experience; • Complaints – improve timeliness and quality of responses; • Carers – improve their involvement in discharge planning and ongoing involvement in decisions; • Consent / shared decision-making – testing the effectiveness of patients’ understanding of their treatment options; • Embed partnership working between the Trust and patients. Priorities for Year One (2016/17):

• Management skill development in place and impacting positively on delivery; • HR workforce planning capabilities are enhanced and rigorous.

Priorities for Year One (2016/17):

• Develop and implement the service line management case for change; • Develop and enable clinical leader capability.

Priorities for Year One (2016/17):

• Stabilise the existing information system (Lorenzo); • Develop and implement service line reporting; Progress the electronic patient record system.

Priorities for Year One (2016/17):

• Maintain current capacity and capability; • Develop a Research and Development Strategy.

Priorities for Year One (2016/17):

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• Work with partners to develop and start to implement the Bristol, North Somerset and South Gloucestershire Sustainability and Transformation Plan; • Work with partners to design and implement plans for Weston General Hospital; • Prioritise improvements to patient flow through NBT working with key stakeholders and partners across the health and care system.

Report to: Trust Board Agenda item: 13

Date of Meeting: 31st March 2016

Report Title: Approval for transfer of Cellular Pathology Service From UHBristol to NBT

Status: Information Discussion Assurance Approval

Prepared by: David Gibbs, Andrew Heryet, Rosemary Quinn, Catherine Baldwin, Mark Orrell, Louise Corrigan

Executive Sponsor (presenting): Chris Burton

Appendices (list if applicable): Appendix 1: Financial Appraisal

Recommendation:

The Board is asked to approve the transfer of the cellular pathology service from University Hospitals Bristol NHS Foundation Trust (“UH Bristol”) to North Bristol NHS Trust (“NBT”) on 1 May 2016, and approve the execution and completion of the legal documentation required to effect such transfer and the provision of cellular pathology services to UHBristol, namely: • Agreement relating to the Transfer of Cellular Pathology Services (“Business Transfer Agreement”) • Agreement for the supply of Cellular Pathology Services (“Service Level Agreement”) • Lease of Part relating to the Paediatric Mortuary, St Michael’s Hospital and Lease of Part relating to Level, Queens building (“Leases”) This paper is to demonstrate that due diligence has taken place and that the combined service will meet the needs of service users across Bristol within the previously agreed financial envelope. The new service will cost £232k more per annum than the current service. The methodology for sharing this cost has been agreed between NBT and UH Bristol. The total cost impact across both organisations is £643k, which includes un-releasable accommodation and overheads costs at UH Bristol.

North Bristol NHS Trust

Executive Summary: The recommendation of the Bristol Histopathology Inquiry was that UH Bristol and NBT work together to create a single cellular pathology service for the greater Bristol area. A business case for the transfer of the service from UH Bristol to NBT was approved by bothTrust Boards in December 2014. This proposal is the final stage of creating such merged service and completes the remaining recommendation of that Inquiry. To enable NBT to provide the service, it has been necessary to create a suitable space in the purpose built Phase 2 Pathology Building at the Southmead site and procure and deploy a cross city laboratory IT system. An Executive led Transfer Project Board has overseen the development of integrated clinical models for delivery of a sub-specialised service with integrated centralised services laboratory functions at the Southmead site (“Core Laboratory”), and an Essential Services Laboratory (“ESL”) on level eight of the Bristol Royal Infirmary and the paediatric mortuary at St Michael’s Hospital, leased to and managed by NBT. As agreed by the Transfer Project Board, a Business Transfer Agreement has been drafted and agreed by the parties to reflect the key terms of the transfer. Further, a Service Level Agreement has been jointly created to manage service delivery to clinical teams that includes KPIs to ensure class leading performance and an innovative service, responsive to the evolving clinical needs of service users. All staff employed and engaged by UH Bristol in the provision of the services have been through a consultation process and will transfer under TUPE from UH Bristol to NBT on 1 May 2016. University of Bristol staff on honorary contracts have also been consulted and their NHS commitments will also transfer to NBT. An organisational development program has been initiated to ensure full integration of the teams; these include the appointment to management posts under the revised structure, a team building event in the new Pathology Building in March 2016 to ensure operational effectiveness, social events both across UH Bristol and NBT teams and across NBT pathology disciplines and a planned launch event for the new service in late summer 2016.

North Bristol NHS Trust

1. Purpose Endocrine: The pathologists will be based at Southmead with all The purpose of this paper is to demonstrate that the transfer of the technical work performed on site. Surgical samples from the cellular pathology service from UH Bristol to NBT is safe, UHBristol will be sent on the hourly transport. sustainable and affordable and that clinical models for service Lead: Dr Mary Brett delivery have been agreed between pathologists and clinical teams in both UH Bristol and NBT. Further, the combined service Gastrointestinal: The pathologists will be based at Southmead will be achieved in line with the business case approved by both with all the technical work performed on site. Surgical samples Trust Boards in December 2014. from UHBristol will be sent on the hourly transport. Frozen sections must be taxied to NBT (arranged by the surgical team with prior booking with the NBT lab). 2. Summary of Clinical Models Lead: Dr Newton Wong

Full clinical models are included as appendices and where Liver: The pathologists will be based at Southmead with all the possible have been signed or confirmed as accepted by the lead technical work performed on site. Surgical samples from pathologist and clinical teams. All leads below refer to Lead UHBristol will be sent on the hourly transport. Pathologists Lead: Dr Behrang Mozayani

Breast: No change to the current provision. The pathologists are Gynae-pathology: The pathologists will be based at Southmead based at Southmead with all the technical work performed on site. with all the technical work performed on site. Surgical samples Lead: Dr Mohammed Sohail from UHBristol will be sent on the hourly transport. Frozen

sections must be taxied to NBT (arranged by the surgical team Respiratory: The pathologists will be based at Southmead with with prior booking with the NBT lab). all the technical work performed on site. Surgical samples from Lead: Dr Penny Tidbury UHBristol will be sent on the hourly transport. Frozen sections will ideally be performed at the ESL and then the slides scanned Haematopathology: The pathologists will be based at to the Core Lab. If this technology does not work then the frozen Southmead with all the histology technical work performed on site. must be taxied to NBT (arranged by the surgical team with prior Surgical samples from UHBristol will be sent on the hourly booking with the NBT lab). The IT solution is currently being transport. Integrated reports will be produced for both Trusts – implemented and trialled. NBT reports will be through HILIS and UHBristol reports will be in Lead: Dr Nidhi Bhatt Clinisys. The associated flow cytometry etc. will be performed in

the originating Trust. UHBristol samples will be booked in by staff Cardiac Surgery The pathologist will be based at Southmead in the Flow Cytometry section at the BRI and the bone marrow with all the technical work performed on site. Surgical samples forwarded (as is the current practice) to NBT. from UHBristol will be sent on the hourly transport. Lead: Dr Judit Sutak Lead: Dr Ed Sheffield

North Bristol NHS Trust

Lead: Dr Anastasios Chatzitolios Head & Neck/OMF: The pathologists will be based at the ESL. Dissection performed by the pathologist will be retained at the Skin: The pathologists will be based at Southmead with all the ESL. All subsequent technical work, and any samples where the technical work performed on site. Surgical samples from pathologist is not involved in the dissection, will be sent to NBT on UHBristol will be sent on the hourly transport. the hourly transport. Frozen sections will be prepared and Lead: Dr Keith Miller reported at the ESL. Slides will be retained at the ESL for 6 months to allow a rapid check of previous cases. Urology: No change to the current provision. The pathologists Lead: Dr Miranda Pring are based at Southmead with all the technical work performed on site. Ophthalmology: The pathologists will be based at Southmead Lead: Dr Jon Oxley with all the technical work performed on site except for samples sent to the Royal Liverpool Hospital for specialist reporting. Cervical cytology: No change to the current provision. The Surgical samples from UHBristol will be sent on the hourly pathologists are based at Southmead with all the technical work transport. performed on site. Lead: None named Lead: Dr Penny Tidbury

Bone/soft tissue: The pathologists will be based at Southmead Non cervical cytology: The pathologists will be based at with all the technical work performed on site. Surgical samples Southmead with all the technical work performed on site. from UHBristol will be sent on the hourly transport. Cytology samples from UHBristol will be sent on the hourly Lead: Dr Francesca Maggiani transport. H&N cytology which requires specialist reporting will be sent to the ESL via the hourly transport. Paediatrics & Perinatal: The pathologists will be based at Lead: Dr Mary Brett Southmead with all the technical work performed on site. Post mortems will be performed at the St Michael’s mortuary. Frozen Please note: sections associated with Hirschprung bowel resections will be • There is no proposed change to MDT attendance for any prepared and reported at the ESL. Frozen section requiring clinical team. ACHe staining will be forwarded to the Core Lab for cutting and • All slides and blocks will be stored at NBT prior to long staining. Fresh tumours will be handled at both sites but cases that arrive after 5 pm may be refrigerated overnight and samples term offsite storage unless stated. taken the next day. • Any tissue taken and stored at -70°C will be retained at Lead: Dr Silvia Planas the Core Lab under the HTA licence held by NBT. If the tissue is taken at the ESL it will be transferred to the Core Renal: No change to the current provision. The pathologists are Lab within 7 days to comply with HTA regulations. based at Southmead with all the technical work performed on site.

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3. Governance - reporting of serious / unexpected findings - issuing of oral reports 1. Assurance of service quality will be gained through - employment of locums accreditation with UKAS / CPA and HTA, and through - specialist roles and role of specialist team leads assessment by Cancer Peer Review teams, PHE Screening - content of reports programmes and Care Quality Commission. - independent reporting by trainees

2. The governance of the service will be primarily managed 8. Appropriate to their specialty, each Consultant will participate within the existing structures of Pathology Sciences and NBT. in: Responsibilities of individuals will be defined and terms of - Clinical Audit Programme reference of management groups will be documented. - [External Quality Assessment Programs] ("EQA") - [Multi-Disciplinary Team Meetings] ("MDT") 3. A joint Management Board of NBT and UH Bristol managers, - continuing professional development ("CPD") cancer leads and service users will be established, in - appraisal accordance with the terms of the Service Level Agreement. - job planning Governance arrangements will be included within the terms of reference of such Board. 9. Activity and performance of individuals and teams will monitored and reported at appropriate intervals. 4. At regular intervals, the department will undertake a survey to gauge views of service users as to whether the service has 10. Non-medical staff will: met their needs. - be subject to regular competence assessment - participate in appraisal / performance review 5. Incidents and complaints will be managed through existing - demonstrate continuing professional development relevant departmental and NBT processes guided by the Royal and appropriate to role College of Pathologists’ procedure ‘Management of Discrepancies’. Reporting mechanisms will be established 11. Technical processes will be subject to appropriate EQA such that where an incident impacts upon patients within schemes or inter-laboratory comparisons. another organisation, there is a defined communication route. All KPIs will be reported and reviewed and, where 6. A service-specific Risk Register will be maintained and performance is below standard, an action plan put in place to subject to regular review. bring about improvement.

7. There will be a defined approach, in line with guidance issued by the Royal College of Pathologists, to: - double reporting

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4. Business Transfer Agreement (“BTA”)1 “woodwork” employees not required by NBT. Indemnities from NBT in respect of post-transfer 4.1. The parties have agreed to enter into a BTA to document liabilities. Equitable allocation of flexi-time and leave and contractually bind them to the terms of the transfer. pre and post-transfer Whilst previous transfers between the parties have been on an informal basis, without a legally enforceable BTA in 4.3.4. Customer contracts – NHSE and CCG commissioned place, the parties acknowledge the significant benefits of services to be included within NBT 2016/17 contracts. entering into a formal BTA and this approach was approved Other customer contracts to be incorporated into by the Transfer Project Board. existing NBT contracts, or new contracts to be granted by NBT where current arrangements are on an informal 4.2. The BTA is based on the standard DH template, originally basis drafted for the divestment of PCT provider arms under Transforming Community Services (“TCS”), updated and 4.3.5. Data – Agreed arrangements in respect of transfer of, developed through its use by NBT on a number of and access to, soft copy and hard copy records relating subsequent transfers. to the services

4.3. The BTA covers the following key elements of the transfer: 4.3.6. Transitional costs – Payable by UH Bristol quarterly in arrears in accordance with the agreed financial 4.3.1. Assets – Transfer of equipment (agreed list at net book arrangements (see below) value and remainder for £1) and stock (i.e. consumables and products) at purchase price 4.3.7. Support services and contracts – Estates services to be included within the leases to be granted by UH Bristol, 4.3.2. Property – Terms of NBT occupation of the ESL and St and contract change notices (“CCNs”) to be agreed with Michael’s Mortuary will be formalised in leases granted Roche Diagnostics Limited by UH Bristol to commence on 1 May 2016 4.3.8. Liability – Apportionment of liabilities (including clinical 4.3.3. Staff – Application of TUPE or “deemed transfer” in negligence) and debts between the parties on a pre / respect of agreed list of transferring staff. Agreement post-transfer basis, supported by mutual indemnities that University of Bristol staff engaged in the provision of the services will hold new honorary contracts with 4.3.9. Warranties – Specific warranties provided by UH Bristol NBT (and UH Bristol where continuing to work from the in respect of key issues and information provided, ESL or St Michael’s mortuary). Indemnities from UH supported by an indemnity Bristol in respect of pre-transfer liabilities and 4.3.10. Information – Standard provisions regarding data protection, confidentiality and freedom of information 1 Copies of the working draft BTA and SLA can be provided on request This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under a 'closed section' of any meeting. 6

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5.3.3. Termination – Mutual rights of termination for breach of 4.4. The BTA constitutes a clear record of all of the agreed contract, including UH Bristol’s failure to pay the arrangements in respect of the transfer, including complete contract price lists of each aspect of the services transferring to NBT. It ensures an appropriate allocation of liability between the 5.3.4. Staff – TUPE on commencement of the services is parties, which is fair and reasonable. addressed in the BTA. The parties expect TUPE to apply on termination or expiry of the services. However, if TUPE does not apply, UH Bristol shall be 5. Service Level Agreement (“SLA”) liable for any redundancy costs or other losses connected to the redundancy of any employees 5.1. The parties have agreed the terms of an SLA to manage the engaged by NBT in providing the services (provided provision of cellular pathology services from NBT to UH that NBT follows due process and takes all reasonable Bristol after completion of the transfer for a term of five steps to mitigate such costs and losses). Indemnities years (with an option for the parties to extend such term by from NBT in respect of pre-transfer liabilities, and further periods of five years). indemnities from UH Bristol in respect of post-transfer liabilities 5.2. The SLA is based on the NBT standard service contract, and has been amended to reflect the standard terms 5.3.5. Information – Standard provisions regarding data required by UH Bristol’s legal team. The specifications, protection, confidentiality and freedom of information clinical models and KPIs have been developed in collaboration between the parties. 5.3.6. Governance arrangements – Creation of a Management Board and regular meetings, with 5.3. The SLA covers the following key elements of the services: reporting requirements (as above)

5.3.1. Provision of the services – Compliance with all relevant 5.3.7. Performance management – KPI’s have been drafted laws and standards based on the Royal College of Pathologist’s recommendations. Performance mechanism based on 5.3.2. Liability – Standard indemnities for losses arising in that contained within the NHS Standard Contract respect of property and injury to person, due to fraud, 2015/16, including contract performance notices, negligence or breach of contract by the other party. remedial/immediate action plans, contract management Cap on NBT’s total liability (as provider of the services) meetings, joint investigations, financial sanctions and of £1,000,000 exception reports

5.3.8. Price – Financial schedule to reflect the agreed prices payable by UH Bristol (as below)

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integrate the two teams; and both Trusts are working 5.3.9. Specification and clinical models – (See above) collaboratively to develop a staff engagement event prior to the transfer date to give staff an opportunity to work together (The above sections highlighted yellow are to be agreed on some aspects of their future working arrangements. NBT between the parties) induction for transferring staff will take place at UH Bristol prior to the transfer. 6. HR Processes 7. Infrastructure Developments

The HR processes for the transfer of staff into the merged Buildings service have been governed by the Joint Workforce Group which comprises management, HR and staff side A partial hand-over of the Phase 2 Pathology Building at the representation from both Trusts. 34 members of staff are Southmead site was completed in January 2016. The areas still due to transfer under TUPE, including 6 Consultants. A held by the contractor include the Category 3 Laboratory Suite, further 3 Academic Consultants employed by the University the attached corridor, stairwell for access and the outside space. These will not impact on provision of cellular pathology services. of Bristol, who deliver clinical work under honorary contracts at UH Bristol, will also move into the merged service. A “Day one projects” are underway and are on track for completion collaborative approach has been taken to the consultation of in mid-March 2016. These include benching, reception and the UH Bristol staff and the University staff. TUPE equipment installation that will impact on cellular pathology consultation for UH Bristol staff began prior to the original services. This is on track to be completed as planned. planned transfer date, and has been refreshed in March 2016 for the anticipated transfer date of 1 May. The Laboratory Information Management System (“LIMS”) management and administration structure of the future merged service was developed in March 2015, and after There have been significant delays in the LIMS project across joint consultation with staff from both Trusts, the proposed NBT, UH Bristol, Weston Area Health Trust (“WAHT") and Public structures were adopted and staff were informed of their Health England (“PHE”). The implementation of LIMS was noted as a prerequisite in the paper that went to both Trust Boards in future roles, so they are ready to move straight into their December 2014. However, an interim IT solution has been tested new posts at the point of transfer. Formal notice of the and agreed by both Trusts (via the Project Transfer Board), using transfer will be given to staff as soon as confirmation of the existing IT systems together with the new sample tracking system transfer date has been received from both Trust Boards. that will be operational in April 2016, and will allow the transfer to occur before the implementation of LIMS. The project is now on In addition to formal consultation procedures, there have target for “go-live” in the week beginning 16th May 2016. also been a number of joint social events that are helping to

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There are several key milestones to be met before a Go/No Go decision can be made, these are: 18th March 2106 – UAT completion, no further software changes required 1st April 2016 – Suppliers deliver final software update 15th April 2016 – Software drop UAT completed 13th May 2016 – Blood transfusion end to end test passed 13th May 2016 – End User Training at 80% minimum

Transport

Hourly daytime transport arrangements have been arranged in conjunction with infection sciences services and will meet the routine requirements of the service.

Additional urgent transport, including frozen sections from UH Bristol theatres, has been tested and performance agreed with surgical teams.

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7. Financial Analysis

REVENUE

Income & Expenditure

The table below shows the summarised income and expenditure for the current service at each organisation, compared with the future service model. Appendix 1 shows the income and expenditure in further detail.

The total current cost of the service (based on 2014/15 outturn) is £11.2m, after removing recharges between the two organisations. NBT’s cost is £7.3m and UH Bristol’s cost is £3.9m. The recurring cost of the future service is £11.4m, which is an additional cost of £0.2m.

INCOME & EXPENDITURE 2014/15 POSITION FUTURE INCREASE/ NBT UHB TOTAL SERVICE (DECREASE) £000 £000 £000 £000 £000 Funding Sources Income 2,904 1,227 4,131 4,131 0 Tariff 4,422 2,652 7,074 7,074 0 Total Funding 7,326 3,879 11,205 11,205 0 Expenditure Pay 4,723 2,544 7,267 7,263 (4) Non-pay 1,354 742 2,096 2,140 44 Premises & Capital Charges 347 319 666 858 192 Overheads 902 274 1,176 1,176 0 Total Expenditure 7,326 3,879 11,205 11,437 232 Total Surplus / (deficit) (0) 0 (0) (232) (232)

The additional cost of £232k per annum is due to:- 1) Increase in cost of MDTs due to travel costs.

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2) Increase in accommodation costs, as a result of the move into the new Pathology building at NBT. 3) Revenue impact of investment in IT and equipment.

The table below shows the funding sources for the future service cost of £11,437k per annum. The MDT cost increase will be met by UH Bristol. The remaining gap of £182k will be allocated across service commissioners, based on income.

FUNDS OF FUTURE SERVICE AT NBT Current MDT Remaining Total Funds Increase Gap Funds £000 £000 £000 £000 Commissioning income GP Direct Access 192 0 3 195 Paediatric/Perinatal Pathology 544 0 9 553 Other 1,758 0 30 1,788 Total Commissioning Income 2,494 0 43 2,537 Non commissioning income 1,167 0 20 1,187 MADEL 360 0 0 360 Charge to UHB for MDTs 305 50 0 355 Charge to UHB for specimens based on current value 2,457 0 44 2,501 NBT funding from tariff for MDT 278 0 0 278 NBT funding from tariff for specimens 4,144 0 75 4,219 Total income 11,205 50 182 11,437

The transfer of commissioning income from UH Bristol to NBT will be part of the agreement for the 2016/17 Commissioning Contract.

Transitional costs

The non-recurring transitional costs total £90k over a 5 year period. It has been agreed that these costs will be shared equally between NBT and UH Bristol, resulting in a cost of £45k to each organisation spread over a 5 year period.

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TRANSITIONAL COSTS 2016/17 2017/18 2018/19 2019/20 2020/21 TOTAL £000 £000 £000 £000 £000 £000 Excess travel 11 12 12 11 1 47 Clinical leadership 30 30 Removal & installation costs 13 13 Total 54 12 12 11 1 90

The phasing by year is based on an estimated transfer date of 1st May 2016. The phasing will change if the transfer date changes.

Organisation Impact

The table below shows the income and expenditure for the current service at each organisation (2014/15), compared with each organisation’s future position. The overall impact of the transfer is an additional cost of £643k per annum.

Income & Expenditure Impact by Organisation:

UHB NBT TOTAL Current Post Impact Current Post Impact Impact of Service Transfer of Service Transfer of Transfer Transfer Transfer £'000 £'000 £'000 £'000 £'000 £'000 £'000 Change in Income SLA Income (802) (110) 692 (1,802) (2,494) (692) 0 In Tariff Funding (2,652) (2,652) 0 (4,422) (4,422) 0 0 Training Income (148) 148 (212) (360) (148) 0 Recharge UHB - MDTs 0 (355) (355) (355) Recharge UHB - 0 (2,457) (2,457) (2,457) Specimens Recharge UHB - Gap 0 (44) (44) (44)

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Recharge (43) (43) (43) Commissioners - Gap Recharge Other Income (20) (20) (20) - Gap Recharge of Space - (41) (41) 0 (41) ESL Recharge of Space - (69) (69) 0 (69) Mortuary Other (277) 277 (890) (1,167) (277) 0 Total Change in (3,879) (2,872) 1,007 (7,326) (11,361) (4,035) (3,028) Income

Change in Expenditure Pay 2,544 0 (2,544) 4,723 7,263 2,540 (4) Non Pay 742 (742) 1,354 2,139 785 43 Site Accommodation 169 169 0 198 281 83 83 Capital Charges - 141 141 0 149 467 318 318 Buildings Capital Charges - 9 0 (9) 0 (9) Equipment NBT Recharge - MDTs 355 355 0 355 NBT Recharge - 2,457 2,457 0 2,457 Specimens NBT Recharge - 44 44 0 44 Contribution to Gap UHB Recharge - ESL 0 41 41 41 UHB Recharge - 0 69 69 69 Mortuary Divisional Overheads 74 74 0 213 287 74 74 Corporate Overheads 200 200 0 689 889 200 200 Total Change in 3,879 3,439 (439) 7,326 11,436 4,110 3,671 Expenditure

Net Impact (0) 568 568 0 75 75 643

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Note: the current service income and expenditure includes inter Trust recharges.

UH Bristol Financial Impact

The financial impact on UH Bristol is shown as a loss of £568k.

This impact is understood and accepted; provision has been made in the Trust’s 2015/16 budget. The loss is explained as follows: £’000

Diseconomy on corporate overheads 274 Diseconomy on premises costs 200 Share of overall increased service costs - Travel costs for MDTs 50 44 - Increased cost of new lab building at Southmead

Total Loss 568

The corporate overheads diseconomy is offset by offsetting service transfers in to the Trust (e.g. Specialist Paediatrics). The premises diseconomy is offset by the release of substantial floor area on BRI levels 8 and 9 which will be re-used to provide a restaurant facility and other accommodation that enables the BRI Old Building to be fully closed in 2016.

This re-use is supported by a capital investment of c. £2m to re-furbish and re-develop the space previously used by Pathology services such as Histopathology and Microbiology (Public Health England) moving to Southmead.

The financial impact assumes that the Paediatric & Perinatal Pathology SLA is rebased to increase its value by £101k due to the current non-payment by results SLA being understated when costed in 2009/10. This rebasing has been actioned within UHB’s 14/15 commissioner SLA.

This will be made neutral by a compensating adjustment to the non-payment by results discount line in the SLA. This does however require commissioner (NHS England) agreement.

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NBT Financial Impact

The impact on NBT is a cost pressure of £75k per annum. This will be dealt with through the budget setting process for 2016/17. The NBT position assumes that commissioners and other customers pick up a share of the additional accommodation and IT/equipment costs. This equates to an increase of 1.7%.

There will be a formal SLA (as above) to cover the recharge from NBT to UH Bristol for specimens and MDTs, covering an initial period of 5 years. This will include the methodology for the annual uplift. The annual uplift will include efficiency of 0% for the first 3 years. Inflation will be cost based and will be agreed annually. The recharge will be a block contract in year 1, with a shadow tariff developed. The block value will be £2,501k for specimens (plus inflation for 2015/16 and 2016/17) and £355k for MDTs (plus inflation for 2015/16 and 2016/17). Negotiations with commissioners will be required to secure a similar arrangement on inflation and efficiency for direct access and paediatric/perinatal pathology.

CAPITAL

There is a capital requirement of £300k for NBT including VAT. This will be included in the capital plan for 2016/17.

CAPITAL COSTS £000 IT pathology speech module 21 IT pathology speech users 71 Equip - UHB microscopes 48 Equip - UHB space at NBT 70 PC rebuild, ports & handsets 20 Purchase of UHB equip 43 Contingency 27 Total 300

UH Bristol will commit circa £2m capital to converting and refurbishing BRI levels 8 and 9.

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Financial Risks

Risk Mitigation Increase / decrease in activity leading to Block recharge in first year to allow for over / under recovery of costs and shadowing of the new contract and full exposing one Trust or another to assessment of the impact of transfer and unplanned cost pressure. negotiation on management of this impact between the two Trusts.

Any change in UH Bristol activity during Agree a mechanism to amend block 2015/16 and 2016/17 will not be reflected contract if activity change is significantly in the block recharge for the first year (as above/below 2014/15. Address in the the block will be based on 2014/15 outturn Service Level Agreement. plus inflation). Difficulty in recruiting to permanent posts New service model provides attractive and therefore risk of increasing agency / locum stable opportunities for prospective / send away test costs. members of staff.

Contract notice period. Risk to continuity of Full Service Level Agreement developed service, short-term expensive measures and agreed between the two Trusts. being used to manage activity should Agreed to 5 year contract period initially contract notice period not be sufficient to (without any right of early termination) to put in place alternative provider (UHB) / allow the service to embed and develop. find alternative source of income (NBT). Other provider-to-provider arrangements in existence already.

Risk of redundancy cost if UH Bristol does Risk addressed in the SLA. not extend the contract at the end of 5 years. National tariff changes. Risk of reduced Risk exists regardless of service transfer. income from commissioners. Changes in the funding of outpatient and inpatient

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diagnostics would change financial impact by Trust and the overall service.

Higher than planned for transport costs. Robust financial planning and maximum utilisation of existing transport.

Higher than planned for direct costs. Robust financial planning and strong negotiation with suppliers to realise economies of scale.

Consultant WTE included in the funded Update workforce plan following establishment is not sufficient to deliver integration. workload. Non commissioning income lower than Robust financial planning. planned for.

Capital not available to IT and equipment Consider lease option investment.

Financial model fails to provide resources Block in first year covering over 65% of to deliver service current UH Bristol income. Service does not allow the generation of UH Bristol have agreed that efficiency will efficiency savings be 0% in first 3 years. Workload figures for two clinical models Further workload analysis will be required (Haematopathology and Dermatology) do to assess that current PA provision is not equate to current PA provision included sufficient to cover workload. Current in I&E shortfall equivalent to 9 DCC PA’s (£123k)

(The above sections highlighted yellow are to be agreed between the parties)

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8.Time-Line for service moves into Pathology Services Building

Bold Activities involving UH Bristol Cellular Pathology Red Dates to be confirmed

Day Date Month Department Antimicrobial Assay Laboratory Tuesday 15 March (NBT Lime Walk) Genetics (NBT Phase1), Monday 11 April Antimicrobial Assay (NBT Lime Walk)

Tuesday 12 April Genetics (NBT Phase1)

Wednesday 13 April Genetics (NBT Phase1)

Thursday 14 April Genetics (NBT Phase1)

Friday 15 April Genetics (NBT Phase1) Saturday 16 April Sunday 17 April Monday 18 April Bacteriology (NBT Lime Walk) Histology (NBT Lime Walk), Genetics (NBT Phase 1) and Tuesday 19 April Cytology Training School (NBT Lime Walk)

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Day Date Month Department NBT Cell Path Consultants, Secretaries, Specialist Registrars Wednesday 20 April and Audit Clerks, Histology and Cytology NBT Cell Path Histology, Thursday 21 April Cytology, Consultants, Secretaries, Consumables Stores

Any residual items Bacteriology Friday 22 April and Cellular Pathology (NBT Lime Walk) Saturday 23 April Sunday 24 April NBT Cell Path Audit Clarks, Monday 25 April Managers and the Archive Store Neuro Pathology (NBT Lime Tuesday 26 April Walk)

Wednesday 27 April Tidy Up Day, Neuro

Histology Equipment from UH Thursday 28 April Bristol

Tidy Up Day, Neuro and Friday 29 April Antimicrobial Assay

Saturday 30 April Complete Histology UH Bristol

Sunday 31 April Complete Histology UH Bristol

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Day Date Month Department Monday TUPE transfer of all UH Bristol (Bank 1 May Staff Holiday) Commence integrated cellular Tuesday 2 May pathology service NBT Phase 2 Monday 16 May LIMS Go-Live Relocate PHE Bacteriology from TBC May? UHB with possible exception of CAT 3

Relocation of Molecular and TBC September Mycology Services from Myrtle Road

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9. Recommendations The recommendation is to approve the transfer of the Cellular tariff will be developed during year one, so that cross charging Pathology service from UH Bristol to NBT to form a single service from year two will be volume based. for Bristol, on 1st May 2016. This is in line with the outcome of the Key performance indicators based on the Royal College of Bristol Histopathology Inquiry and completes the final outstanding Pathologists guidelines have been agreed and will be monitored actions from that Inquiry. This will centralise most services at the by the Management Board. This Board will agree jointly on Southmead site, and also create an Essential Services Laboratory remedial actions should performance not meet the agreed at the BRI to enable provision of local services where clinically trajectory for improvement. required. A joint Management Board will be formed to oversee performance, manage the Service Level Agreement and enable All MDT functions will continue as is, but the pathology input for the service to continually evolve to meet the clinical needs of the both Trusts will be provided by the integrated NBT team. The service users in both Trusts. mass of the combined service will allow final adoption of a fully sub-specialised service model with greater resilience and ability to The Service Level Agreement will initially be for 5 years with costs innovate. in year one based on current expenditure. However, a shadow

APPENDIX 1 CELLULAR PATHOLOGY SERVICE TRANSFER COMPARISON OF FUTURE SERVICE MODEL WITH CURRENT COST ACROSS NBT & UHB At 14/15 prices FUTURE RECURRING 2014/15 POSITION ** SERVICE INCREASE/ NBT UHB TOTAL MODEL (DECREASE) £000 £000 £000 £000 £000 FUNDING SOURCES

INCOME Commissioning income 14/15 outturn 1,802 591 2,393 2,393 0 Rebase paed pathology block 0 101 101 101 0 MDTs 0 110 110 110 0 Total commissioning income 1,802 802 2,604 2,604 0

Other income Non commissioning income 890 277 1,167 1,167 0 Inter Trust Recharges 0 0 0 0 0 MADEL income 212 148 360 360 0 Total other income 1,102 425 1,527 1,527 0

Total Income 2,904 1,227 4,131 4,131 0

TARIFF IP/OP * 4,144 2,457 6,601 6,601 0 MDTs 278 195 473 473 0 Total tariff funding 4,422 2,652 7,074 7,074 0

TOTAL FUNDING 7,326 3,879 11,205 11,205 0

EXPENDITURE Direct Costs Pay 4,723 2,544 7,267 7,263 (4) Non-pay Direct costs 872 446 1,318 1,320 2 MES 482 296 778 820 42 Non-pay sub-total 1,354 742 2,096 2,140 44

Direct costs sub-total 6,077 3,286 9,363 9,403 40

Premises & Capital Charges Premises 198 169 367 281 (86)

Capital Charges Buildings & Equipment 149 150 299 425 126 New equipment 0 0 0 42 42 Capital charges sub-total 149 150 299 467 168

UHB ESL & Paed mortuary lease 0 0 0 110 110 EM prep space 0 0 0 0 0

Premises & capital charges sub-total 347 319 666 858 192

Overheads Directorate overheads 213 74 287 287 0 Corporate Overheads 689 200 889 889 0 Overheads sub-total 902 274 1,176 1,176 0

TOTAL EXPENDITURE 7,326 3,879 11,205 11,437 232

TOTAL SURPLUS / (DEFICT) (0) 0 (0) (232) (232)

* Figure assumed to be total expenditure less external income. ** 2014/15 postion includes includes 14/15 outturn excluding inter-Trust recharges.

Report to: Trust Board - Public Session Agenda item: 14

Date of Meeting: 31 March 2016

Report Title: Capital Planning Update

Status: Information Discussion Assurance Approval

X X

Prepared by: Martin Warren, Project Manager

Executive Sponsor (presenting): Simon Wood, Director of Facilities

Appendices (list if applicable): Capital Planning Report

Recommendation:

The Trust Board is asked to note the position on each issue and the principal actions being taken to address them

Executive Summary: See following report.

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1. Purpose & background 1.1 The attached report updates on progress and issues in relation to the PFI Phases 1 & 2 and as well as Capital Projects.

2. PFI Phase 1

2.1 The key risks and challenges are set out on the attached report under Phase 1 Compliance Issues which are reviewed and managed at regular meetings with Carillion 3. PFI Phase 2 3.1 Carillion are now confirming that the forecast completion of Phase 2 of the Brunel building will be in July 2016, although the date is jointly under review. 3.2 The discussions and negotiations on responsibility for delays are continuing. 3.3 Carillion are not responding as well to compliance issues identified during the joint assurance visits to construction areas. 4. Capital Projects 4.1 The largest delay to the PFI Phase 2 Works Area relates to the Limewalk Building, which hopefully will be vacated by Pathology teams by the end of April 2016. 4.2 The consequence of this is that works will be unable to start for the road infrastructure works for the new Southmead Way before the completion of the rest of PFI Phase 2. The resultant delay disruption and costs are still being assessed by the Project Team. 4.3 Apart from Neuropath, the Frenchay Decommissioning is complete. 5. Recommendations 5.1 The Trust Board is asked to note the current position and actions.

This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under a 'closed section' of any meeting. 2 Capital Planning Report 23 March 2016 PFI Phase 1 Compliance Issues Top 10 tasks from helpdesk February 2016 On PFI Phase 2 Progress Issue Next Action Required R.A.G track Action Status A/C-Too Cold 121 AGV R&M Handover of Works Areas: The Trust has Costs being considered in order to Fittings-R&M 141 handed over all works areas with the exception Theatre Flooring Staining NBT Green developed counter charge variation to THC. Blinds-R&MAGV R&M 142 of Limewalk area. The date for vacating R Joint Working group established task and Blinds-R&M 147 Limewalk is now April 2016 but depends on finish groups to review the Trust and Lighting-R&M completion of Pathology 2 Compliance CSL Amber Lighting-R&M 159 Carillion polices, roles and responsibilities Construction Progress: Carillion have Internal Door-R&M 201 of each compliance service package Internal Door-R&M confirmed that completion of all of Phase 2 will R Sink-R&M 203 Program of works is slow. This has been be July but the date is still under review escalated to Carillion board and further Powered Doors-R&MSink-R&M 279 Fire Integrity CSL Red Construction Quality: The Trust and its resource has been allocated to speed up Toilet-R&M 322 Powered Doors- advisers are making regular visits within the resolution of issues. R&MFogging 1250 Brunel building extension. Carillion are only Amber Working group set up to review the options 0 100 200 300 attending to some compliance items raised with Critical Care & Theatre 0 200 400 600 800 1000 1200 1400 CCL to increase the ventilation rates in the Amber Ventilation them. Others are not obviously being resolved sterile preparation room. PFI Phase 2 Key Issues yet.

Outpatients Level 1 solution trial to be Delay to Phase 2: On Capital Projects Door Review CSL reviewed end of Mar and main revolving Green Carillion have confirmed that actual completion of Phase 2 of Track door full review end of July 2016. the Brunel building and externals will now be July. Pathology 1.. New Roche Equipment installed in autolab. New Sysmex system validated and old system removed. The validation has taken Working group including CSM’s and CSL Delay to Pathology Planned Preventative longer than planned but now the old system is removed the benching CSL established to agree coordination of Green The final extent of the Pathology Phase 2 delay is still uncertain, R Maintenance (PPM) st periodic tasks. and delayed completion means moves from Limewalk are in reconfiguration in autolab can be completed by 1 April. The final Work started in ED prior to Christmas. April 2016. Demolition and site clearance will run into the 3rd phases of work on the first floor will then be undertaken once Genetics High patient numbers in ED causing quarter. The works to build the new Southmead Way will take have relocated to Phase 2 in mid-late April 16. difficulties with access to complete work. place after the completion of the rest of PFI Phase 2 Flexible Duct Replacement CCL Red Pathology 2: Day 1 projects ongoing. Office furniture installation Further access being negotiated. st Compliance inspections have identified complete. Indicative date for CAT 3 handover is end of 1 week in June further incomplete remedials. Frenchay Projects On Track but this is subject to receiving full programme and replacement filter th R The remedial flushing regimes are boxes arriving on time NBT moves will start on 11 April and will result in Decommissioning: Complete, apart from Neuropath G Replacement taps indicating an improved position. Taps are Lime Walk being vacated by the end of April, allowing decontamination Residential Land: Conditional exchange of contracts programme in augmented CCL being replaced in ICU only in the Green with Redrow achieved. Redrow to satisfy outstanding A and decommissioning to commence. care areas immediate future. With other augmented conditions precedent Thornbury: OBC for disposal approved at February Trust Board G care areas being risk managed. Public Open Space: Registration as Village Green Sample strip approved by IPC. Program and Transfer to Winterbourne Parish Council are A Sherston and Brecon: Buildings were decommissioned July 2015. issued and being considered with clinical being progressed. Mitigations to deal with possible vibration and dust during demolition and R Bathrooms Pod Floor CCL teams. Impact and disruption minimal. Green Frenchay Park House disposal: FBC approved by construction of car park have been discussed with Medical Director. Target completion end of August across all Trust Board. Contracts exchanged on 28th November G Scheme approved at EAMCPG but deferred until 2017/18 2015, completion due within 18 months. wards. Bath Renal Satellite Unit: 20 station option approved at EAMCPG, HSCC Land: OBC for disposal submitted to March key: Red No plan to resolve G however OBC now deferred until April to allow robust workup of 3rd party Trust Board A Amber Solution agreed but not started Beckspool House Car Park -Car Park to be re- revenue option, and inclusion of business case for central dialysate. A Green On programme provided following demolitions, which are underway. Outline Planning permission due to be submitted.

Report to: Trust Board Agenda item: 15

Date of Meeting: 31 March 2016

Report Title: Review of Partnership Arrangements with University Hospitals Bristol NHS Foundation Trust

Status: Information Discussion Assurance Approval

X X

Prepared by: Eric Sanders, Trust Secretary, NBT

Executive Sponsor (presenting): Andrea Young, Chief Executive, NBT

Appendices (list if applicable): Appendix 1 – Partnership Arrangement Appendix 2 – Terms of Reference for the Partnership Programme Board Appendix 3 – Draft Work Programme for the Partnership Programme Board

Recommendation:

The Trust Board is asked to: • Approve the Partnership Agreement document • Approve the revised Terms of Reference for the Partnership Programme Board • Note the continued desire to work more closely together

University Hospitals Bristol NHS Foundation Trust North Bristol NHS Trust

1. Purpose 2.4. The Trust’s in-house commercial legal advisers 1.1. To present a revised approach to the working have reviewed the document and are satisfied with its contents. In reflecting the fact that the agreement relationship with the University Hospitals Bristol NHS has no legal basis, the document is now called a Foundation Trust and seek approval for a reviewed Partnership Arrangement and not a Partnership Partnership Arrangement document and Terms of Agreement. Reference for the Partnership Programme Board 3. Revised Approach to the Partnership 2. Background 3.1. There are two ways in which the partnership should 2.1. The Partnership Agreement was approved by the be considered. Firstly how the partnership can Boards of the two organisations in November 2010. influence and shape the environment within which it The agreement reflected the positons and working operates and secondly how the individual parties arrangements of the organisations at that point in operate within the partnership. The combination of time and therefore it is timely to review the document these two perspectives should be used to inform the to update it in light of current local, regional and vision and strategic direction for the partnership. national context. 3.2. In relation to how the partnership can influence the 2.2. The purpose of a partnership agreement is to set out external environment, the following principles are how the two parties will work together, the principles proposed: on which this joint working will be based and the headline structure for how this will delivered. • The partnership should be the “acute voice of Bristol” and should use this combined power to 2.3. It was agreed at the Partnership Programme Board, influence local and regional commissioning and held on 25 September 2015, to review the policy decisions, contract negotiations, the partnership arrangements with the view to reframing research agenda, development of provider the agreement in early 2016. The proposed changes networks and service reconfiguration. were discussed by the individual Executive teams of the two organisations, prior to joint discussion at the • The partnership should actively promote the Executive to Executive meeting held on 11 January positive outcomes of acute provision in Bristol to 2016. The Partnership Programme Board then help build its reputation and should be seen as an considered the principles and behaviours which were exemplar for joint acute working and used to develop the revised Partnership collaboration. Arrangement at its meeting on 25 January 2016. University Hospitals Bristol NHS Foundation Trust North Bristol NHS Trust

• The partnership should seek to improve the consideration of the partnership, which it is proposed outcomes for the patients in its local and are used to shape more detailed operational work. specialist catchment areas. The principle of a higher level description provides a clear, yet unrestricted, framework within which the • The partnership should assist in improving the partners can operate. efficiency and economy of the whole health system. 4.2. The original document also describes how the work of the partnership would be undertaken in two 3.3. In relation to the internal mechanisms of the phases. Whilst this level of detail is helpful to give partnership, there is broad agreement that the examples of how the partnership might operate it following principles should be adopted: can, as highlighted above, be restrictive. • There is benefit in the alignment of organisational 4.3. To retain clarity about what the partnership will do in strategies. practice, it is proposed to develop a work plan (draft • From this alignment there will be clarity of where presented in Appendix 2) which will be reviewed further collaboration maybe delivered and equally annually and can be tailored to the needs of the where the two parties may compete. partnership. • The partnership should set its self a set of 5. Proposed Behaviours measureable objectives which are used to drive 5.1. In terms of behaviours, the 7 principles of public life forward this work and demonstrate its success. should be adhered to. Examples of how these could • Sharing of learning across organisational be applied have been described below: boundaries would add significant value. 1. Selflessness – The two Trusts should work 3.4. It was further recognised that there needed to be a together in the best interests of the public served, clear communication strategy to ensure that staff predominantly but not limited to the populations understood the working arrangements and what this of BNSSG. meant for them as employees of the partners. 2. Integrity – Officers of the two Trusts’ should not 4. Comparison with the Existing Partnership try to gain financially or materially from any Agreement decision. Any interests must be declared and resolved. 4.1. The eight principles described above, approach the partnership from a different perspective than in the original document. The eight are a higher level

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University Hospitals Bristol NHS Foundation Trust North Bristol NHS Trust

3. Objectivity – decisions must be impartial, fair described below and are presented in Appendix 2 and on merit, using the best evidence and without with tracked changes: discrimination or bias. 6.1.1. Change of references from Partnership 4. Accountability – The responsibility and Agreement to Partnership Arrangement, as accountability for activities must be clarified to described above. ensure that scrutiny can be directed 6.1.2. Confirmation of NBT’s membership as two appropriately. Therefore for key projects it would Non-Executive Directors (Robert Mould and be good practice to agree a lead Trust. Nishan Canagarajah), Chief Executive, Medical 5. Openness – The Trust’s should be open and Director and another Executive Director to be transparent with the information they share to confirmed. ensure objectivity in decision making. This would 6.1.3. That the host organisation for each meeting include sharing of financial, operational and will chair that meeting. Meetings alternate quality information. between the two organisations, with three 6. Honesty – At all times the Trust’s should be meetings per year. truthful in the information they provide to the 6.1.4. Administration for the Partnership Programme other party and how this information is presented Board and Executive to Executive meetings will so that it is not misleading. rotate between the Trust Secretaries of the two 7. Leadership – Officers of the Trust should organisations with UH Bristol taking over actively and positively promote the partnership administration from 1 April 2016. and the operations of the other Trust. Where 7. Recommendations there is the potential for negative reputational impact, this should be highlighted to the other 7.1. The Trust Board is asked to: Trust in advance so that there can be consistency • Approve the Partnership Agreement document in communication. • Approve the revised Terms of Reference for the 6. Revised Terms of Reference Partnership Programme Board 6.1. The Terms of Reference for the Partnership • Note the continued desire to work more closely Programme Board have also been reviewed to together ensure they are consistent with the revised Partnership Agreement. The main changes are

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Appendix 1 Partnership Arrangement between North Bristol number of circumstances, there may also be opportunities to NHS Trust and University Hospitals Bristol NHS work together (subject to obtaining and complying with Foundation Trust appropriate legal advice). The partnership will set itself a set of measureable objectives, Date: which will be used to drive forward this work and demonstrate Initial term: 3 years its success. The Trusts will also seek to share learning across Principles of the Partnership organisational boundaries to help drive forward operational The two above named Trusts have worked in partnership and clinical service improvement. since 2010 and they have agreed to enter into this updated partnership arrangement to reflect the principles of how they To deliver the principles, the Trusts will form a Partnership will work together going forward. The principles are as follows: Programme Board, which will have equal representation from the two Trusts, and which will be formed from the Non- • The partnership should be the “acute voice of Bristol” and Executive and Executive memberships of the separate Boards should use this combined power to influence local and of Directors. This is not a formal subcommittee of either regional commissioning and policy decisions, contract Board. The Terms of Reference are appended in Annex 1. negotiations, the research agenda, development of provider networks and service reconfiguration. The Partnership Programme Board will be supported by an Executive to Executive meeting, which will oversee the • The partnership should actively promote the positive operational implications of the partnership. outcomes of acute provision in Bristol to help build its reputation and should be seen as an exemplar for joint The Partnership Programme Board will develop a work plan, acute working and collaboration. which will be reviewed annually and tailored to the needs of the partnership. Such work plan will reflect the commercial • The partnership should seek to improve the outcomes for principles underlying the partnership and the benefits to be the patients in its local and specialist catchment areas. obtained by both Trusts. The work plan for 2016/17 is • The partnership should assist in improving the efficiency appended at Annex 2. and economy of the whole health system. Expected Behaviours Implementation of the Arrangement In terms of the behaviours of the Trusts, the seven principles To support the delivery of the principles, the Trusts will seek of public life should be adhered to as follows: to align their organisational strategies and identify where 1. Selflessness – The two Trusts should work together in further collaboration may be delivered. Whilst the Trusts the best interests of the public served, predominantly, acknowledge that they may compete with each other in a but not limited to, the populations of BNSSG.

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Appendix 1 2. Integrity – Officers of the two Trusts should not try to 7. Leadership – Officers of each Trust should actively and gain financially or materially from any decision. Any positively promote the partnership and the operations interests must be declared and resolved. of the other Trust. Where there is the potential for 3. Objectivity – Decisions must be impartial, fair and on negative reputational impact, this should be highlighted merit, using the best evidence and without to the other Trust in advance so that there can be discrimination or bias. consistency in communication. 4. Accountability – The responsibility and accountability for activities must be clarified to ensure that scrutiny Resources and Confidentiality can be directed appropriately. For key projects, it is This partnership does not commit either Trust to sharing considered to be good practice to agree a lead Trust. resources. The requirement to commit resources will be 5. Openness – The Trusts should be open and considered on an individual project basis. Resources in this transparent with the information they share to ensure context include capital, revenue and workforce capacity. objectivity in decision making. This includes sharing Information shared will remain the property of the Trust which financial, operational and quality information. released the information and shall be treated as confidential. 6. Honesty – At all times the Trusts should be truthful in Explicit, written consent is required to share information the information they provide to the other and how this outside of the partnership. information is presented, so that it is not misleading.

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Appendix 3

Proposed Work Plan 2016/17

June 2016 October 2016 January 2016 Assessment of alignment between Winter resilience approach Contractual negotiation and business operational Strategies Cellular Pathology Transfer review and planning alignment Update on actions to support Weston lessons learnt Risks and actions related to the local five year Sustainability and Transformation Plan1 Thematic review of service transfers

1 https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf

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Appendix 2 Terms of Reference - Partnership Programme Board

Version Tracking Version Date Revision Description Editor Approval Status

0.1 27/01/2011 Draft for consideration by the Trust HH & DL Draft Boards of Directors of UH Bristol and NBT

0.2 08/02/2011 Revisions recommended by Trust CH Draft Secretary of UH Bristol with regard to Foundation Trust governance

0.3 10/02/2011 Redraft agreed CH Draft

1.0 28/02/2011 Approved by the Trust Board of Directors CH Approved

2.0 09/07/2011 Revisions requested by June Partnership DL Draft Programme Board

3.0 24/02/2016 Update to align to revised Partnership Draft Arrangement and confirm the agreed changes to chairing and secretariat support.

15. Partnership Programme Board App 2 - Revised Draft (ES) 240216.doc Terms of Reference - Partnership Programme Board

Table of Contents

1. Constitution ...... 3 2. Authority and Accountability ...... 3 2.5. Limitations ...... 3 3. Purpose...... 4 4. Membership ...... 4 4.6. Quorum ...... 5 4.7. Secretariat Services ...... 5 5. Attendance ...... 6 6. Meetings ...... 6 6.2. Frequency of meetings ...... 6 6.3. Notice of meetings ...... 6 6.4. Minutes of meetings ...... 6 6.5. Public Access and Confidentiality ...... 7 6.6. Annual General Meeting ...... 7 7. Reporting ...... 7 8. Monitoring and Review ...... 7

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1. Constitution

1.1. The Trust Boards of Directors (the Boards) of University Hospitals Bristol NHS Foundation Trust and North Bristol NHS Trust have resolved to establish a joint overview board that shall be known as the North Bristol NHS Trust and University Hospitals Bristol NHS Foundation Trust Partnership Programme Board (the Partnership Programme Board).

1.2. The Partnership Programme Board is established to oversee the collaboration and joint working described in the Partnership Agreement Arrangement approved by both Trust Boards in November 2010 – See “Appendix A – Partnership Agreement”.

1.3. The creation of the Partnership Programme Board is recognition by the two Trust Boards of Directors of the importance of collaboration and joint working for the benefit of the patients, carers and staff of both Trusts, and that of the wider health community.

1.4. The Partnership Programme Board has no executive powers other than those derived from its membership (i.e. the powers of Executive Directors) or those specifically delegated in these Terms of Reference.

2. Authority and Accountability

2.1. Members of the Partnership Programme Board remain accountable to the Boards of Directors of their respective Trusts

2.2. The Partnership Programme Board is authorised by the Boards to investigate any activity within its terms of reference.

2.3. The Partnership Programme Board is authorised to seek any information it requires from any officer of the Trusts via their respective Chief Executive, and all officers are directed to co-operate with any request made by the Partnership Programme Board via their respective Chief Executive.

2.4. The Partnership Programme Board may obtain whatever professional advice it requires1, and may require Directors or other officers to attend meetings.

2.5. Limitations

2.5.1. Save as is expressly provided in Standing Orders and Standing Financial Instructions of the respective Trusts, the Partnership

1 The Partnership Programme Board may, from time to time, contract specialists to advise and support the discharge of these terms of reference. This shall be funded by both Trusts subject to Partnership Programme Board recommendation and budgetary approval by both Trusts. For legal advice, this shall be subject to consultation with the Trust Secretary’s of University Hospitals Bristol NHS Foundation Trust and North Bristol NHS Trust the designated legal services lead for NBT, and the availability of an approved budget.

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Programme Board shall have no further power or authority on behalf of the Trust Board’s of University Hospitals Bristol NHS Foundation Trust and North Bristol NHS Trust.

3. Purpose

3.1. The purpose of the Partnership Programme Board is:

3.1.1. to ensure that the Partnership Agreement Arrangement continues to benefit the patients, carers and staff of both Trusts and that of the wider health community; and,

3.1.2. to make recommendations to the Trust Boardss of Directors on any changes to the Partnership Agreement Arrangement considered necessary and appropriate.

3.2. The Partnership Programme Board shall:

3.2.1. eEndeavour to enable the maximum contribution of staff of both organisations towards the success of the Partnership Agreement,Arrangement,

3.2.2. Ssupport the spirit of collaboration and joint working between the two Trusts,

3.2.3. dDetermine the priorities for partnership working between the two Trusts

3.2.4. Oversee and ensure delivery of the work programme plan priorities

3.2.5. Identify and resolve any obstacles that impede the progress of partnership working

3.2.6. Sponsor the work to identify the optimal acute service configuration(s) for the City and ensure any subsequent work arising from this is progressed satisfactorily

4. Membership

4.1. The following shall be members of the Partnership Programme Board:

4.2. North Bristol NHS Trust:

4.2.1. Chief Executive

4.2.2. Director of Organisation, People & Performance

4.2.3.4.2.2. Medical Director

4.2.4.4.2.3. Another Executive Director

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4.2.5.4.2.4. Two [2] Non-executive Directors, both of whom shall be independent2 Non-executive directors.

4.3. University Hospitals Bristol NHS Foundation Trust:

4.3.1. Chief Executive

4.3.2. Director of Strategy

4.3.3. Medical Director

4.3.4. Two [2] Non-executive Directors, both of whom shall be independent3 Non-executive directors.

4.4. The Chairmanship of the Partnership Programme Board shall alternate between two nominated Non-executive Directors of the two Trusts who will chair when they are hosting the meeting.

4.5. In the absence of both of the Programme Board Chairmen, the remaining members present shall elect one of the other Non-executive Director members to chair the meeting.

4.6. Quorum

4.6.1. The quorum necessary for the transaction of business shall be four [4] members, of whom two must be Non-executive Directors and two [2] must be Executive Directors (Executive Directors or the Chief Executive)4.

4.6.2. A duly convened meeting of the Partnership Programme Board at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Partnership Programme Board.

4.7. Secretariat Services

4.7.1. The Chief Executives of each Trust shall, in consultation with the Trust Secretary, make available such secretariat services as are necessary to support the work of the Partnership Programme Board.

4.7.2. This shall include the provision of a secretary to the Partnership Programme Board, and such other services as are required from time to time.

2 i.e. shall not have been employed by the Trust in the three [3] years preceding their appointment as Non- executive Director.as defined within the Trust’s Standing Orders 3 As defined within the Trust’s Constitution i.e. shall not have been employed by the Trust in the three [3] years preceding their appointment as Non-executive Director. 4 i.e. One Executive Director and one Non-executive Director from each Trust.

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4.7.3. The secretary to the Board will be provided on an annual, rotational basis, with University Hospitals Bristol NHS Foundation Trust providing secretariat support from 1 April 2016 to 31 March 2017.

5. Attendance

5.1. Only members of the Partnership Programme Board have the right to attend meetings. However, other officers and external advisers may be invited to attend for all or part of any meeting as and when appropriate and where no conflict of interest exists.

5.2. The Trust Secretary’s from the respective Trust’s will be expected to attend the meeting to provide governance and legal advice.

5.3. The University Hospitals Bristol NHS Foundation Trust Secretary shall attend from time-to-time to provide advice to the Directors; and to facilitate the formal evaluation of the Partnership Programme Board’s performance.

6. Meetings

6.1. Meetings of the Partnership Programme Board shall be conducted in accordance with the following provisions:

6.2. Frequency of meetings

6.2.1. The Partnership Programme Board shall meet three times per year and at such other times as the Chairmen of the Partnership Programme Board shall require as advised by the Secretary.

6.3. Notice of meetings

6.3.1. Meetings of the Partnership Programme Board shall be called by the Secretary of the Partnership Programme Board at the request of the Chairmen.

6.3.2. Unless otherwise agreed, notice of each meeting confirming the venue, time and date, together with an agenda of items to be discussed, shall be made available to each member of the Partnership Programme Board, any other person required to attend and all other members of the Trust Boards of Directors, no later than five [5] working days before the date of the meeting.

6.3.3. Supporting papers shall be made available to Partnership Programme Board members and to other attendees as appropriate, and to all other members of the Trust Boards of Directors no later than five [5] working days before the date of the meeting.

6.4. Minutes of meetings

6.4.1. The secretary shall minute the proceedings and resolutions of meetings of the Partnership Programme Board, including the names of those present and those in attendance.

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6.4.2. Draft Minutes of meetings shall be made available promptly to all members of the Partnership Programme Board and, once agreed, to all other members of the Trust Boards of Directors5.

6.5. Public Access and Confidentiality

6.5.1. There is nothing within the Constitution of the University Hospitals Bristol NHS Foundation Trust Constitution which requires the meetings of this Partnership Programme Board to be held in public, or to allow public access. Personal information shall be subject to the provisions of the Data Protection Act 1998; other information shall remain subject to the Freedom of Information Act 2000.

6.5.2. All members and attendees shall have due regard to the confidentiality of any discussions relating either to identifiable individuals, or to commercially confidential information.

6.6. Annual General Meeting

6.6.1. The Partnership Programme Board Chairmen shall attend the Annual General Meeting of the partner organisation and be prepared to respond to any stakeholder questions on the Partnership Programme Board’s activities.

7. Reporting

7.1. The Chairman of the Partnership Programme Board (or Chief Executive of each Trust) shall report formally to his Trust Board on all proceedings and matters within the duties and responsibilities of the Partnership Programme Board.

7.2. The minutes of Partnership Programme Board meetings shall be formally recorded and submitted to the Trust Boards according to the Boards’ Annual Reporting Cycles.

7.3. The Chair of the Partnership Programme Board shall make whatever recommendations to his Trust’s Board of Directors he deems appropriate on any area within the Partnership Programme Board’s remit where disclosure, action or improvement is needed.

7.4. The Partnership Programme Board shall make available, in the form of a report, suitable information on Partnership Programme Board policy, practices and undertakings for publication in the Trusts’ annual reports.

8. Monitoring and Review

5 Unless a conflict of interest exists.

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8.1. The Trust Secretary shall, at least once a year, review the performance, constitution and terms of reference of the Partnership Programme Board to ensure it is operating at maximum effectiveness.

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Report to: Trust Board Agenda item: 16

Date of Meeting: 31 March 2016

Report Title: Workforce Committee Terms of Reference

Status: Information Discussion Assurance Approval

Prepared by: Eric Sanders, Trust Secretary

Executive Sponsor (presenting): Paul Jones, Interim Director of People and Organisational Health

Appendices (list if applicable): Appendix 1 – Draft Workforce Committee Terms of Reference

Recommendation:

The Trust Board is asked to approve the Terms of Reference and approve Dr Liz Redfern as the Chair of the Committee.

North Bristol NHS Trust

1. Purpose 3.3. It is proposed that the Committee meets every two months, in between meetings of the Quality & Risk 1.1. To present the draft Workforce Committee Terms of Management Committee. Reference to the Board for approval. 3.4. The primary role and function of the Committee is as 2. Background follows: 2.1. In Quarter 4 2014/15 the Trust Board sought • Developing and advising the Board on a additional focus on the workforce planning workforce strategy, taking into account relevant arrangements in the Trust, which resulted in the best practice and alignment with strategic approval of a workforce plan in April 2015. objectives 2.2. In monitoring progress of the original plan, it has • Reviewing the senior leadership succession and become apparent that the plan was overly optimistic development plans and actions were insufficient to deliver the desired • Maintaining general oversight of the Trust’s targets. Human Resources function and capability to support strategic objectives 2.3. In considering the Board’s role in the effective • Monitoring the development of the future oversight and scrutiny of the workforce, the Board workforce, through a ‘fit for purpose’ workforce has recognised that the current arrangements are plan, aligned with finance and activity for the insufficient. It therefore agreed in January 2016 to Trust convene a dedicated Workforce Committee, as a • Monitoring an agreed set of workforce related sub-committee of the Board, to provide the required Key Performance Indicators level of strategic oversight and challenge. • Ensuring that feedback from the National Staff 3. Workforce Committee Survey, GMC Survey and pulse surveys are 3.1. Following the agreement to convene a Workforce appropriately analysed, and improvement Committee, Terms of Reference have been drafted actions taken to support employee engagement and are presented in Appendix 1. and desired organisational culture • Maintaining oversight of the Trust’s employment 3.2. It is proposed that the Non-Executive Director related diversity agenda membership of the committee includes Dr Liz • Ensuring that the HR and workforce Redfern and Robert Mould. development perspective is represented throughout the strategy and policy development work of the organisation

North Bristol NHS Trust

• Overseeing the development and implementation of policy and working practices which support the Trust as a major Teaching Hospital. • Providing Board level leadership in creating an “employer of choice” working environment • Oversee and influence key relationships with educational and partner organisations to maximise the benefit of these relationships to the Trust. • Other HR related activity as requested by the Board

4. Recommendations 4.1. The Trust Board is asked to approve the Terms of Reference and approve Dr Liz Redfern as the Chair of the Committee.

Committee Terms of Reference

Workforce Committee Terms of 1. Authority 1.1. The Trust Board hereby resolves to establish a committee of Reference the Board to be known as the Workforce Committee. 1.2. The Committee is constituted as a standing committee of the Purpose - The Trust Board has approved the establishment of Trust Board. Its constitution and terms of reference shall be the Workforce Committee (known as “the Committee” in these as set out below; and will be subject to amendments terms of reference) for the purpose of approved by the Trust Board. a) providing strategic direction and board assurance in 1.3. The Committee is authorised to seek information it requires relation to all workforce matters. from any employee of the Trust. All members of staff are b) making recommendations, as appropriate, on workforce directed to co-operate with any request made by the matters to the Trust Board. Committee. The Committee is authorised to obtain legal or c) determining those matters delegated to the Committee other independent professional advice and to secure the in accordance with the Scheme of Delegation and attendance of such outsiders with relevant experience and Standing Financial Instructions expertise that it considers necessary. d) assessing and identifying risk within the Workforce and 1.4. The Committee is authorised by the Board to make Organisational Development portfolio and escalating decisions within its terms of reference, including matters this as appropriate specifically referred to it by the Board.

Date Adopted TBC 2. Membership 2.1. A Non-Executive Director, appointed by the Board, will Review Frequency Bi-Annual chair the meetings of the Committee. 2.2. The core membership of the Committee will include: Core Accountabilities • 2 x Non-Executive Director (Committee Chairman and Deputy Chair) Terms of reference drafting Trust Secretary • Director of People and Organisational Health • Review and approval Workforce Committee Director of Nursing • Director of Finance Adoption and ratification Trust Board • Director of Facilities 2.3. Deputies may attend with the permission of the

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Workforce Committee Terms of Reference Approved by the Trust Board TBC

Committee Chairman. • Monitoring an agreed set of HR related Key Performance Indicators • Ensuring that feedback from staff surveys are appropriately 3. Quorum analysed, improvement actions taken where necessary to 3.1. Quorum will be achieved through the presence of three drive employee engagement and desired organisational members of the Committee. Quorum must include a Non- culture Executive Director, the Director of People and • Maintaining oversight of the Trust’s employment related Organisational Health and at least one other Executive diversity agenda Director. • Ensuring that the Trust has a suitable framework to deliver 3.2. Deputies do not count towards the determination of the strategy and HR policy of the organisation. Ensuring whether a quorum is present. these align with the relevant CQC and TDA workforce standards. 4. Attendance • Overseeing the development and implementation of initiatives 4.1. On invitation from the Chairman of the Committee, to maintain the organisation as a major Teaching Hospital meetings may be attended by any other person who has • Providing Board level leadership in creating an ‘employer of been invited to attend the meeting by the Committee choice’ working environment Chairman. • Oversee and influence key relationship with educational 4.2. Members are expected to attend at least five meetings partners to maximise the benefit of these relationships to the per year. Deputies do not count towards the attendance Trust. target. • Other HR related activity as requested by the Board

5. Roles and responsibilities 6. Conduct of business 5.1. The primary role and function of the Committee is as 6.1. The PA to the Director of Workforce and Organisational follows: Health will provide the administrative support to the • Developing and advising the Board on a workforce strategy Committee and will be the secretary to the Committee. taking into account relevant best practice and alignment with The PA will: strategic objectives for the Trust • provide timely notice of meetings • Reviewing the senior leadership succession and • forward agendas and supporting documents to development plans members and attendees in advance of the meetings • Maintaining oversight of the Trust’s Human Resources 6.2. In exceptional circumstances, the Chairman of the function Committee may make other arrangements for secretarial • Monitoring the development of the future workforce, through support in instances where the confidentiality of a ‘fit for purpose’ workforce plan information and discussion dictates. 6.3. The Trust Secretary will provide professional oversight to

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Workforce Committee Terms of Reference Approved by the Trust Board TBC

the support to the Committee. 10.2. Full minutes of the Committee will be sent in confidence to all members of the Committee, regardless of whether they attended. These shall also be made available, on 7. Frequency request, to the NHS Trust Development Authority and the 7.1. The Committee shall meet six times per year. Further Trust’s internal and external auditors. meetings can be called at the request of the Committee 10.3. The Trust Secretary will prepare a report of the decisions Chairman or on the advice of the Director of People and of the Committee which will be presented to the Trust Organisation Health. Board following each meeting. The report will address the main items discussed and decisions made by the Committee. The report will confirm that the Committee 8. Notice of meetings has discharged its responsibilities, as set out in these 8.1. The annual meetings of the Committee will be set in terms of reference. The report will not include specific advance as part of the planning of the Trust Board and detail relating to individuals or the deliberations of the Committee meetings annual calendar. Committee. 8.2. An agenda of items to be discussed will be forwarded to each member of the Committee and any other person required to attend, no later than five working days before 11. Review the date of the meeting. Supporting papers will be sent to 11.1. The Committee will review these terms of reference bi- Committee members and to other attendees as annually. appropriate, at the same time. 11.2. This Committee will also undertake an annual self- 8.3. In normal circumstances, a minimum notice period of two assessment of its effectiveness in discharging its weeks must be given for any other meetings of the responsibilities as set out and in delivering against the Committee. Emergency meetings can be arranged, at needs of the Trust. shorter notice, if this is approved and evidenced as such 11.3. Its conclusions and recommendations for change will be by the majority of the members of the Committee. reported for approval to the Board.

9. Decisions of the Committee 9.1. Decisions may be taken by written resolution upon the agreement of the majority of members of the Committee in attendance, subject to the rules on quorum stated earlier.

10. Reporting 10.1. Formal minutes of Committee meetings will be recorded.

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Report to: Trust Board Agenda item: 17

Date of Meeting: 31 March 2016

Report Title: Declarations of Interest 2015/16

Status: Information Discussion Assurance Approval

Prepared by: Eric Sanders, Trust Secretary

Executive Sponsor (presenting): Andrea Young, Chief Executive

Appendices (list if applicable): None

Recommendation:

The Trust Board is asked to note the report

Executive Summary:

Under the Standards of Business Conduct for NHS Staff, the Codes of Conduct and Accountability, the Professional Standards of Board Members and to help comply with the Bribery Act 2011 all voting members of the Trust Board must declare any relevant and material interests and those declarations must be recorded in the Public Minutes. The declarations (including ‘nil responses’) set out in the appendix have been made.

In addition, Declarations of Interest, including nil returns, have been requested from all Corporate Directors, Clinical Directors, General Managers and other relevant staff. These forms will be available for inspection from the secretary to the Trust Board.

North Bristol NHS Trust

NORTH BRISTOL NHS TRUST

TRUST BOARD 31st MARCH 2016

Declarations of Interest 2015/2016

BOARD MEMBER INTEREST DECLARED

1. Mr Peter Rilett 1. Non-Executive Director of: Chairman Watts of Lydney Ltd Bordeaux Quay Ltd Business West Ltd

2. Trustee of: St. Monica’s Trust

3. Wife is Trustee of Bristol Charities and Governor of University of West of England

2. Mr Robert Mould 1. Member of: Non-Executive Bristol Mediation

3. Ms Elizabeth Redfern 1. Director/Owner of: Non-Executive Director Liz Redfern Partnership

2. Associate of Foresight Partnership

North Bristol NHS Trust

4. Mr Andrew Willis 1. Associate of: Non-Executive Director King’s Fund Hay Group

2. Non-Executive Director of: Royal Devon and Exeter NHS Foundation Trust

3. Chairman of: United Communities Housing Association

4. Trustee of: EDP Drug and Alcohol Services

5. Professor Nishan Canagarajah 1. Pro-Vice Chancellor of: Non-Executive Director University of Bristol

6. Mr Ken Guy 1. Trustee of: Non-Executive Director Milestones Trust Penny Brohn Cancer Care

2. Independent Member of Bristol City Council Audit Committee

7. Mr John Everitt 1. Trustee of: Non-Executive Director Guide Dogs Blind Children UK 2. Daughter is Trust Fund Raiser for Royal United Hospital, Bath

North Bristol NHS Trust

8. Ms Andrea Young None Chief Executive

9. Mrs Catherine Phillips None Director of Finance

10. Mrs Sue Jones None Director of Nursing

11. Dr Christopher Burton 1. Secondary Care Doctor on Dorset Care Medical Director Commissioning Group

12. Ms Kate Hannam, None Director of Operations

Report to: Trust Board Agenda item: 18

Date of Meeting: 31 March 2016

Report Title: Annual Cycle of Business 2016-17

Status: Information Discussion Assurance Approval

Prepared by: Eric Sanders, Trust Secretary

Executive Sponsor (presenting): Peter Rilett, Chairman

Appendices (list if applicable): Appendix 1 - Annual Cycle of Business 2016-17

Recommendation:

The Trust Board is asked to: • Consider the content of the annual cycle of business to confirm it meets the information needs of the Board • Consider the frequency of items and whether these are sufficient • Approve the annual cycle of business 2016-17, subject to any changes identified

North Bristol NHS Trust

1. Purpose Where possible reports, which should be in the public domain, are reported in the months where the 1.1. To present the annual cycle of business for the Trust Trust Board meets in public. Where this has not Board for approval been possible, the reports will be published on the 2. Background Trust website to allow for public scrutiny. 2.1. The Trust Board should have a clear programme of 3.3. The cycle also includes a number of annual reports work for the year which describes the timing and which the Board should consider each year. A review frequency of the regular reports that will be has been undertaken to refine the list of reports presented and considered. presented to the Trust Board based on legislative or contractual requirements, and those which are more 2.2. The governance review, commissioned by the Trust appropriate for sub-committee review. The reports in 2014, highlighted the need for greater focus on which must come to the Trust Board are listed below: this key governance document, and proposed that the cycle of business is audited each year to confirm • Doctor Revalidation that it has been applied and completed as agreed by • Health & Safety the Board. This will now be scheduled into the • Emergency Preparedness, Resilience and internal audit plan. Response • Environmental Sustainability (included within the 2.3. The review also highlighted the need for the Board to Trust Annual Report) regularly consider the long term financial viability of • Safeguarding Children the Trust, particularly when considering key business • cases or service changes. Safeguarding Adults • Equality & Diversity 3. Overview of the Cycle of Business • Complaints and Patient Feedback 3.1. The cycle of business is split into four overarching 3.4. All annual reports will in future be published on the sections: Trust website for ease of public access. 1. Quality 3.5. The cycle of business has been shared with the 2. Strategy & Planning Executive Directors to ensure accuracy of the timing 3. Operational Performance of items during the year. 4. Governance, Risk & Regulatory

3.2. The reports are then scheduled by month, based on historic reporting and good practice requirements.

North Bristol NHS Trust

4. Recommendations 4.1. The Trust Board is asked to: 4.1.1. Consider the content of the annual cycle of business to confirm it meets the information needs of the Board 4.1.2. Consider the frequency of items and whether these are sufficient 4.1.3. Approve the annual cycle of business 2016-17, subject to any changes identified

Trust Board Annual Cycle of Business 2016/17

Private Only Private Only Private Only Private Only Private Only Private Only

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Quality Patient Story Story (SJ) Story (SJ) Story (SJ) Story (SJ) No meeting planned Story (SJ) Story (SJ) Story (SJ) No meeting Story (SJ) Story (SJ) Story (SJ) planned Complaints Annual Report 15/16 (SJ) Surveys Patient Survey (SJ) National Staff Survey (PJ)

Staffing 6 Monthly Safe Staffing 6 Monthly Safe Staffing Update (SJ) Update (SJ)

Quality Account Draft Quality Account Final Quality Account 2017/18 Quality Account priorities (SJ) (SJ) (SJ) HSMR/SHMI

Strategy & National Review of:

Planning Operating Framework Outcomes Framework Risk Assessment Trust Strategy Strategy Implementation Review (CB)

Enabling strategies

Annual Report and Accounts Draft Annual Governance Final Annual Report and Annual Review Document (AY) Annual Audit Letter (CP) Statement (AY) Accounts (AY & CP)

Business Plan and Budget Final Plan 2016/17 (CP) 6 Month Review of Draft 2017/18 BP Final Budget (CP) Implementation (CP) and Budget (CP)

Long Term Financial Model LTFM Update (CP) LTFM Update (CP) Key Projects and Developments

Capital Capital Programme Mid- Year Draft Capital Review (SW) Programme 2017/18 (SW)

Well Led Board Report from KPMG (ES)

Operational Integrated Performance Report Monthly Update (AY) Monthly Update (AY) Monthly Update (AY) Monthly Update (AY) Monthly Update (AY) Monthly Update (AY) Monthly Update (AY) Monthly Update (AY) Monthly Update Monthly Update (AY)

Performance (AY)

Commissioning Contract Update on 2016/17 contract Update on Update on 2017/18 agreement delivery (CP) 2017/18 (CP) agreement (CP)

Governance/ Risk/ A dministration Committee Update Committee Update Committee Update Committee Update Reports Committee Update Reports Committee Update Reports Committee Update Reports Committee Update Reports Committee Update Annual Cycle of Business Reports Regulatory Reports Reports Board Development Plan 2015/16 Reports 2017/18 (ES) (PR) Declarations of Interests (ES)

Stakeholder Engagement Academic Health UHB/NBT Partnership Board Academic Health Science BHP Report (AY) BHP Report Academic Health Science Report (AY) Science Network Report Network Report (AY) UHB/NBT Partnership Board Report Network Report (AY) (AY) (ES) UHB/NBT Partnership Board Report (AY)

Effectiveness Reviews (including Trust Board review of Terms of Reference and Audit Committee cycles of business) Quality & Risk Management Finance & Performance Remuneration & Appointments Charitable Funds

Board Risk & Assurance Board Assurance Board Assurance Framework Board Assurance Framework Board Assurance Framework Framework Framework Approval Update (ES) Update (ES) Update (ES) (ES)

Private Only Private Only Private Only Private Only Private Only Private Only

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Professionals under Investigation Quarterly Report (PJ) Quarterly Report (PJ) Quarterly Report (PJ)

Annual Reports Medical Revalidation and Health and Safety (SW) Equality and Diversity (PJ) IG Toolkit Assessment (ND) Appraisal Annual Report (CB) Emergency Preparedness, Resilience and Response (KH) Adult’s and Children’s Annual Reports (SJ)

IPR monitoring includes: Staffing, Workforce, HSMR/SHMI, ED dashboard, RTT, LoS, Patient Flow, Cancer, Serious Incidents, Infection Control, FFT, Complaints, Training, Financial Position

Report to: Trust Board Agenda item: 19

Date of Meeting: 31 March 2016

Report Title: Trust Management Team Update

Status: Information Discussion Assurance Approval

Prepared by: Eric Sanders, Trust Secretary

Executive Sponsor (presenting): Andrea Young, Chief Executive

Appendices (list if applicable): None

Recommendation:

The Trust Board is asked to note the content of this report.

North Bristol NHS Trust

1. Purpose and Neil Darvill were to lead task forces with general managers and heads of nursing to 1.1. To present an update on the business transacted progress improvements in these areas. by the Trust Management Team (TMT) at its meetings held on 19 January, 16 February and 22 3.4. There was appetite expressed by the clinical March 2016. directors for a meeting with executives to understand why the position had arisen and to 2. Background learn lessons and it was hoped to organise this 2.1. The Trust Management Team is the key delivery prior to the end of March 2016. group in the Trust and consists of the Executive 3.5. The TMT meeting in March was given over to a Directors, Clinical Directors and General discussion on the history of the financial position Managers. the current rate of expenditure and what could be 2.2. It is good practice that all Committees which done to drive costs down and increase activity report to the Trust Board should report after each and income. The outcome will form part of the meeting. Board discussion on the financial position. 3. Business Undertaken Lorenzo Stabilisation 3.1. The TMT focused its attention on the following 3.6. TMT was provided with an update at both areas: meetings on the status of the stabilisation stage of the Lorenzo implementation programme. It was Financial Recovery clear that there were issues regarding outpatient 3.2. With a headline deficit at the end of December of data input and coding. This posed potential £38 million and an increase in this figure at the operational and financial risks and are discussed end of January much time was understandably elsewhere in the Board agenda. spent on the actions necessary to recover the position for the current and next years. The Draft Strategy issues have been and are discussed elsewhere 3.7. TMT was given a presentation on the outlines of on the Board’s agenda. the draft Trust strategy with members having been sent prior background information. Chris 3.3. It was clear from discussions that directorate staff Burton emphasised the Trust’s current services, needed better and more up to date financial and its strengths and weaknesses, the activity data with the stabilisation issues for interdependencies of the services and the Lorenzo an important element. Catherine Phillips

North Bristol NHS Trust

fundamental nature of the Trust’s general hospital 3.13. TMT supported the proposal to move the function to its overall services. management of theatres, anaesthetic services, the Intensive Care Unit and the Pain Service into 3.8. It was felt that the Trust must get its fundamental the Surgical Directorate. This would enable a services operating efficiently, that training should coherent and unified approach to various issues be emphasised more strongly in the strategy, to improve gains in productivity. particularly for those below clinical director level and unnecessary complexity simplified. 4. Key Risks Identified and Impact 3.9. TMT expressed strong support for the progress of 4.1. TMT recognised and discussed risks relating to: the strategy • the implementation of Lorenzo. Workforce Controls • the productivity of theatres. 3.10. Paul Jones presented the position and potential • the financial position actions on workforce controls. These included • the future of the BCRM elements to address sickness absence, • Weston services supernumerary policy, recruitment, e-rostering • Further potential action by junior doctors practice, annual leave management, enhanced care and temporary staff. These had the potential 5. Key Decisions to make savings of over £11 million a year. 5.1. TMT approved the following: 3.11. All the proposed actions gained support from the directorates. 5.1.1. The rearrangement of the Surgical and Core Clinical Service Directorates. Fertility Services 5.1.2. The outline of the draft Trust strategy. 3.12. The future of the Bristol Centre for Reproductive Medicine was discussed and the option to enable 5.1.3. Actions to control workforce expenditure. it to preserve its legacy, protect its staff in the 5.1.4. Twelve business cases for 2015/16 and best possible way and minimise the financial support for a further five for the business liability of the Trust was supported. The issue is planning process for 2016/17 discussed elsewhere in the board papers. 5.1.5. The sale of the BCRM service to a company Directorate Changes and the lease of space to it for a limited period.

North Bristol NHS Trust

6. Exceptions and Challenges 6.1. As before timeliness of papers remains an issue with a balance between presenting the most up to date picture with allowing sufficient time for members to read and consider the information presented. 6.2. Further work is required to ensure that the timetable for submissions and distribution of papers is achieved. 7. Governance and Other Business 7.1. The TMT received regular reports, in line with its defined reporting schedule. 8. Future Business 8.1. The TMT will be focusing on the following areas over the next three months: • Financial and operational performance delivery. • Business planning 2016/17.

9. Recommendations 9.1. The Trust Board is asked to note the update provided on the work of the TMT.

Report to: Trust Board Agenda item: 21

Date of Meeting: 31st March 2016

Report Title: Charitable Funds Committee 9th March 2016 Summary

Status: Information Discussion Assurance Approval

X X

Prepared by: Ian Hoddell, Charitable Funds Accountant

Executive Sponsor (presenting): Ken Guy, Non-Executive Director

Appendices (list if applicable): None

Recommendation: The Trust Board is requested to note the key issues from the Charitable Funds Committee Meeting on the 9th March 2016

North Bristol NHS Trust

Charitable Funds Committee meeting held 9th March 2016 exception of the proposed spend on staff benefit which was specifically excluded.

• A new accounting reserves policy was agreed. 1. Fundraising and Fund Governance • • A revised budget for the charity fundraising team was Various requests for funding were considered and some of presented and it was agreed that the 2016/17 budget these were approved. would be £224,308. • An overage arrangement relating to a legacy received was • There was discussion about the appropriateness of spend agreed. of the Charity’s funds in relation to staff benefit following • The terms of reference were presented for consideration. recent Charity Commission communication. It was decided These need to be amended to reflect the changes in that a policy needs to be created to clarify these issues membership and will be circulated and comments received raised. It was decided that spend purely for staff benefit by members. with no demonstrable link to patient benefit would not be allowed in the following year and that there should be 4. Transfers to Other Charities greater alignment of the Charity’s spend with the trust’s • Transfers in respect of CCHP and the Riverside Unit to objectives. charities associated with their respective new providers • The Fundraising plan for 2016/17 was considered and it were approved. Clarification on the ability to use the was that agreed further work needed to be done to refine CCHP funds within the trust was sought prior to the and align with the Trusts capital programme and strategic transfer being finalised. objectives. 5. Investment Report • The investment performance of the investments held by 2. Financial Reporting Smith and Williamson was noted. This performance is still within the target set. • The Christmas Grant programme for 14/15 was discussed and those departments which had not returned receipts disclosed to the committee. The Christmas Grant programme in 2016 will be subject to the rules set out in

the new policy on expenditure as outlined above.

3. Committee Approvals

• The spending plans for the 16/17 financial year were reviewed. This followed a detailed review by a smaller review group. The plans were approved with the

Report to: Trust Board Agenda item: 22

Date of Meeting: 31 March 2016

Report Title: Quality & Risk Management Committee Report

Status: Information Discussion Assurance Approval

X X

Prepared by: Eric Sanders, Trust Secretary

Executive Sponsor (presenting): Rob Mould, Non-Executive Director

Appendices (list if applicable): None

Recommendation:

The Trust Board is asked to: • consider the activities of the Committee and note the assurance provided in relation to Falls Prevention • agree to

North Bristol NHS Trust

1. Purpose 3.3. The expected increase happened but further actions had brought down the rate of falls to the 1.1. To present an update from the Committee national average. The national audit carried out following its meeting held on 21 March 2016. by the Royal college of Physicians (RCP) in 2015 2. Background and a more recent detailed local audit confirmed these figures but showed there was an 2.1. As a formal Committee of the Trust Board, the unexpected increase in the numbers of harmful Committee is required to report after each falls. Of the 30 observations made by the RCP meeting to highlight the key discussions, risks audit only the lack of a non-executive champion identified, decision taken and future business. stood out. The following report provides this update to the Trust Board. 3.4. The local audit identified five potential reasons for this, including patients suffering from delirium not 3. Business Undertaken being managed properly, standing blood pressure Inpatient Falls Prevention not being taken and non-documentation of other patient issues. Study of the themes arising from 3.1. The Committee received a presentation from Dr the root cause analyses (RCAs) of serious Seema Srivistava, Clinical Lead for Falls incidents identified the risks for cognitively Prevention and Associate Medical Director. She impaired patients and those recovering from set out the background of falls in hospital being delirium, patients waiting for discharge and an the most common patient safety incident in British absence of medical assessment of patients at risk hospitals, with a consequent impact on quality of of falls. life, health and health care costs 3.5. A Falls Prevention project won funds from the 3.2. The Committee noted the success of actions Sign up to Safety campaign and this provided taken to prevent falls before the move into Brunel, temporary money for a Band 6 Nurse who had the loose description of the ‘Falls Team’ and the provided face to face training to over 600 nurses composition of the Falls Steering Group that so far, secondment of an Occupational Therapist meets every month. Dr Srivistava also described (OT) for three months, items of equipment and the actions taken to mitigate an expected new interventions. increase in falls when patients moved into single occupied rooms in Brunel. 3.6. Currently the falls rate had shown a 6% decrease from 2014/15 and the serious Incident falls up to a 20% decrease. Dr Srivistava noted, however,

North Bristol NHS Trust

that the challenges faced by the Trust included place a number of infection prevention and the loss of the Sign up to Safety funds and the control and cleaning policies. ending of the roles for the nurse and OT. In 3.11. Nursing teams were responsible for the cleaning addition she was stepping down from the lead of point of care equipment and a review of clinical role but was confident that a nurse or cleaning products had introduced a change from therapist could lead in an even better way. detergent to disinfectant wipes. Sporicidal wipes 3.7. The Committee considered that the trust-wide had proved effective against C Diff and was being campaign needed to be merged into ward based trialled. safety programmes and that it should see some 3.12. Domestic teams were responsible for evidence of the link at a later date. environmental cleanliness and recent actions had Cleaning Responsibilities between Facilities taken place to ensure the hours worked on each and Nursing risk category area complied with British Institute of cleaning science methodology and full 3.8. The Committee received a report on the recruitment was made to domestic posts by the governance processes in place regarding end of March 2016. A review of leadership had infection control and cleanliness of the brought consistency to support domestic staff. environment and point of care of clinical equipment cleaning. 3.13. Credits for Cleanliness and Saving Lives No. 8 Cleanliness of Point of Care Equipment are used 3.9. The Trust had suffered a rise in Methicilin as audit tools by the domestic and nursing teams. Resistant and Methicilin Susceptible These are reviewed within directorates and by the Staphylococcus Aureus bacteraemia as well as in Joint Cleaning Group and Control of Infection Clostridium Difficile infections. There had been Committee. The former provides collaborative much reduced rates of Norovirus and Influenza. working between domestic and nursing teams. The RCAs of each of the incidents of the first three cases had shown some link to lapses in 3.14. Noting the importance of the balance between care and breaches in policy linked to deep cleans and ward activity the Committee contaminated equipment and poor compliance requested further information on the actions taken with environmental cleanliness. possibly linked with the national survey results of cleanliness and food quality. 3.10. The 2008 Hygiene Code set out the responsibilities of individuals and the Trust had in Emergency Preparedness Resilience and Response

North Bristol NHS Trust

3.15. Following the report to the Board in October 3.19. The Committee reviewed the quality sections of 2015, the Committee received assurance that the the Performance Assurance Framework and three standards rated as amber in the noted that work on reviewing quality measures assessment by NHS England and South was still in progress. Gloucestershire of the Trust’s EPRR in 2015 had 3.20. For the next meeting the quality measures would been addressed and were now considered as be drawn out of the 2016/17 business plan and rated green. corporate objectives mapped across. There was Walkrounds agreement that the effectiveness outcomes of each directorate also ought to be included but 3.16. The Committee received the latest update to the these may not be ready until the July meeting. executive and non-executive walkrounds and as requested at the last meeting a schedule of the Quality Account Priorities non-executive walkrounds is included as a 3.21. The Committee learned of the extensive internal separate item on the Board agenda. consultation on the nine potential areas for the Risk Management 2016/17 Quality Account priorities. The top four were: 3.17. The Committee received its regular report on the key operational risks to the organisation and • Involving patients, family and carers in process of continual improvement in the decisions about care and treatment management of risks across the Trust. • Sepsis management 3.18. In discussion, Committee members asked that • the Finance and Performance Committee should Dementia and delirium management review the finance and performance risks and the • End of life care Board should periodically review the extreme 3.22. The Committee endorsed the choices subject to risks. Ideally this should be done in public but the views of the Quality Committee and final there was recognition that, as currently written, approval by the Board in April. the risk descriptions were often inadequate and sometimes misleading. Further work on training Speak Up Guardianship staff was required. 3.23. The Committee noted that as the Speak Up Performance Assurance Framework Guardian Rob Mould would be undertaking some open sessions for staff in the first quarter of 2016/17.

North Bristol NHS Trust

Carer’s Survey 7. Governance and Other Business 3.24 The Committee received a report on the actions 7.1. The results of the effectiveness survey were taken to comply with the national Dementia reviewed. CQUIN to deliver high quality care to people with dementia and to support their carers. 8. Future Business 4. Key Risks Identified and Impact 8.1. The Committee will, at its next meeting, review a schedule of deep dives 4.1. In addition to the specific risks covered in the risk management report the Committee noted the • The impact of staff engagement actions. risks outlined in the Falls presentation and • The quality of maternity services. Cleaning responsibilities and infection control • Outcomes and performance in services including risks pathology and radiology. • The role and impact of the Matron. 5. Key Decisions • The impact and benefits of Lorenzo from a quality 5.1. The Committee approved the following: perspective. 5.1.1. to receive at a later date evidence of the link • The impact of and actions to comply with between trust wide and ward based patient PREVENT. safety programmes particularly regarding 9. Recommendations prevention of falls 9.1. The Trust Board is asked to: 5.1.2. to refer the extreme risks to the Board for noting 9.1.1. consider the activities of the Committee and note the assurance provided in relation to 5.1.3. the quality priorities subject to the opinion of Falls prevention and Cleanliness the Quality Committee responsibilities 5.1.4. the Non-Executive walkround schedule 5.1.5. to receive a further report on cleanliness actions

6. Exceptions and Challenges

6.1. There were no exceptions or challenges identified.

Report to: Trust Board Agenda item: 23

Date of Meeting: 31 March 2016

Report Title: Remuneration & Nominations Committee Update

Status: Information Discussion Assurance Approval

Prepared by: Eric Sanders, Trust Secretary

Executive Sponsor (presenting): Andy Willis, Committee Chairman

Appendices (list if applicable): None

Recommendation:

The Trust Board is asked to note the report from the Committee

North Bristol NHS Trust

1. Purpose 4. Key Risks Identified and Impact 1.1. To present an update from the meetings of the 4.1. The Committee has previously identified the risk of Committee held on 28 January 2016 and 7 March succession planning as a key risk. This will be 2016. considered by the Committee in April 2016. 2. Background 5. Key Decisions 2.1. The Remuneration & Nominations Committee, as a 5.1. The Committee approved the following: mandatory committee of the Board, is required to 5.1.1. Job description and level of remuneration for report to the Board after each meeting. the Director of Purchasing & Supply and 3. Business Undertaken Associate Director of Strategy. 3.1. The Committee has been focusing its attention on 5.1.2. A revised Executive Director contract for all the following issues: new appointments. 3.1.1. Arrangements relating to the Executive 6. Exceptions and Challenges Directors including proposed changes to 6.1. There are no exceptions of challenges to escalate to contracts to ensure compliance with the Fit and the Board. Proper Persons requirements. 7. Governance and Other Business 3.1.2. Reviewing the outcome of the external assurance checks to support the declarations of 7.1. The Chairmanship of the Committee is due to compliance with the Fit and Proper Persons transfer from Andy Willis to John Everitt from 1 April requirements for Executives and the outcome of 2016. Disclosure Baring Checks for Non-Executive 7.2. The Terms of Reference for the Committee are due Directors. to be reviewed in April 2016. 3.1.3. Reviewing and approving the job descriptions 8. Future Business and levels of remuneration for roles considered to be Very Senior Managers. 8.1. The Committee will be considering the following issues in the next 3 months: 3.1.4. Consideration of the extension of the contract for the Interim Director of People and 8.1.1. The outcome of the annual appraisals of the Organisational Health for a period of six months. Executive Directors 8.1.2. High-level succession plans

North Bristol NHS Trust

8.1.3. Annual Board skills and capability review

9. Recommendations 9.1. The Trust Board is asked to note the report from the Committee